Provider Demographics
NPI:1528380219
Name:FAIRCLOTH, SAMANTHA B
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:B
Last Name:FAIRCLOTH
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 1:902 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-3344
Mailing Address - Country:US
Mailing Address - Phone:478-987-1610
Mailing Address - Fax:973-965-4580
Practice Address - Street 1:902 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-3344
Practice Address - Country:US
Practice Address - Phone:478-987-1610
Practice Address - Fax:973-965-4580
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001520235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist