Provider Demographics
NPI:1508538174
Name:NELSON, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:NELSON
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 1:2900 GRAND AVE APT 427
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3220 113TH AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-9573
Practice Address - Country:US
Practice Address - Phone:425-789-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist