Provider Demographics
NPI:1578824074
Name:BRETZ, SAMANTHA R (SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:BRETZ
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 1:3202 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1506
Mailing Address - Country:US
Mailing Address - Phone:216-634-2402
Mailing Address - Fax:
Practice Address - Street 1:3202 W 30TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1506
Practice Address - Country:US
Practice Address - Phone:216-634-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10718235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist