Provider Demographics
NPI:1629291067
Name:ABDUL-SAMAD, AISHA (ST)
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:
Last Name:ABDUL-SAMAD
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1562 OPOSSUMTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4337
Mailing Address - Country:US
Mailing Address - Phone:240-566-3333
Mailing Address - Fax:240-566-3892
Practice Address - Street 1:1562 OPOSSUMTOWN PIKE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4337
Practice Address - Country:US
Practice Address - Phone:240-566-3333
Practice Address - Fax:240-566-3892
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05356235Z00000X
TX108705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD05356OtherLICENSE #