Provider Demographics
NPI:1518572262
Name:SALAZAR, SAMANTHA S (ST)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:S
Last Name:SALAZAR
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:S
Other - Last Name:FURUKAWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ST
Mailing Address - Street 1:1333 GATEWAY DR STE 1014
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2647
Mailing Address - Country:US
Mailing Address - Phone:321-432-2572
Mailing Address - Fax:
Practice Address - Street 1:1333 GATEWAY DR STE 1014
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2647
Practice Address - Country:US
Practice Address - Phone:321-432-2572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9775235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSZ9775OtherSTATE LICENSE
FLSA20264OtherSTATE LICENSE