Provider Demographics
NPI:1407241789
Name:SAMPSON, RAENISE (MA-CCC, SLP)
Entity Type:Individual
Prefix:
First Name:RAENISE
Middle Name:
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:MA-CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 LAKEWOOD CIR
Mailing Address - Street 2:STE A104
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 LAKEWOOD CIR
Practice Address - Street 2:B 119
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-2617
Practice Address - Country:US
Practice Address - Phone:719-332-4689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist