Provider Demographics
NPI:1194001263
Name:KOSTOWICZ, SAMANTHA SUTTON (MACCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:SUTTON
Last Name:KOSTOWICZ
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 SE FORT KING ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2559
Mailing Address - Country:US
Mailing Address - Phone:352-401-7616
Mailing Address - Fax:352-368-7607
Practice Address - Street 1:2303 SE FORT KING ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-2559
Practice Address - Country:US
Practice Address - Phone:352-401-7616
Practice Address - Fax:352-368-7607
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist