Provider Demographics
NPI:1386034841
Name:CARBAJAL, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CARBAJAL
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 1:28425 N BLACK CANYON HWY UNIT 3078
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-7620
Mailing Address - Country:US
Mailing Address - Phone:269-815-2010
Mailing Address - Fax:
Practice Address - Street 1:1930 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7518
Practice Address - Country:US
Practice Address - Phone:480-456-0719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP9237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist