Provider Demographics
NPI:1699191064
Name:NIRMAL SAMANTA SLP
Entity Type:Organization
Organization Name:NIRMAL SAMANTA SLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIRMAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SAMANTA
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:573-450-3393
Mailing Address - Street 1:250 BRANDY LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-8443
Mailing Address - Country:US
Mailing Address - Phone:573-450-3393
Mailing Address - Fax:573-339-0911
Practice Address - Street 1:250 BRANDY LN
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-8443
Practice Address - Country:US
Practice Address - Phone:573-450-3393
Practice Address - Fax:573-339-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty