Provider Demographics
NPI:1558615583
Name:RUSSELL, SAMANTHA MICHELLE (SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4609 SAN DARIO AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-5773
Mailing Address - Country:US
Mailing Address - Phone:956-723-6600
Mailing Address - Fax:956-723-6614
Practice Address - Street 1:245 LISMORE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78260-4313
Practice Address - Country:US
Practice Address - Phone:956-236-8535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107527235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist