Provider Demographics
NPI:1619587128
Name:SOPHIEA-FAIRMONT, SAMANTHA JULIET (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JULIET
Last Name:SOPHIEA-FAIRMONT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W HILL ST APT 810
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-2535
Mailing Address - Country:US
Mailing Address - Phone:517-927-0202
Mailing Address - Fax:
Practice Address - Street 1:400 LINDEN AVE STE 11
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-3607
Practice Address - Country:US
Practice Address - Phone:517-927-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.005472235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist