Provider Demographics
NPI:1497482004
Name:GUMULA, SAMANTHA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GUMULA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13125 MEADOWBREEZE DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-7944
Mailing Address - Country:US
Mailing Address - Phone:561-767-1665
Mailing Address - Fax:
Practice Address - Street 1:7301 W PALMETTO PARK RD STE 207A
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3456
Practice Address - Country:US
Practice Address - Phone:561-571-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist