Provider Demographics
NPI:1114485570
Name:TAN, SAMANTHA (MS CCC-SLP, CLC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MS CCC-SLP, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12168 MONOGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 W VENTURA BLVD STE 150
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-9140
Practice Address - Country:US
Practice Address - Phone:805-383-1497
Practice Address - Fax:805-383-1498
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist