Provider Demographics
NPI:1326569948
Name:MURDOCK, SAMANTHA LYNN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:MURDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 OAKMONT AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3541
Mailing Address - Country:US
Mailing Address - Phone:937-643-1981
Mailing Address - Fax:
Practice Address - Street 1:430 E PEASE AVE
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-1357
Practice Address - Country:US
Practice Address - Phone:937-859-5121
Practice Address - Fax:937-859-5250
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.2017382-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty