Provider Demographics
NPI:1669630919
Name:HERNANDEZ, SAMANTHA GOGARTY (SLP)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:GOGARTY
Last Name:HERNANDEZ
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 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:3661 S MIAMI AVE STE 409
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4230
Practice Address - Country:US
Practice Address - Phone:305-854-5971
Practice Address - Fax:305-858-6654
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9473235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001417300Medicaid