Provider Demographics
NPI:1710266978
Name:HAFKESBRING, SAMANTHA RAE PENCE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:RAE PENCE
Last Name:HAFKESBRING
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 1:1404 CEDAR RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083-9090
Mailing Address - Country:US
Mailing Address - Phone:503-703-8996
Mailing Address - Fax:
Practice Address - Street 1:1200 HIGHWAY 100
Practice Address - Street 2:SUITE 9
Practice Address - City:PORT ISABEL
Practice Address - State:TX
Practice Address - Zip Code:78578-2462
Practice Address - Country:US
Practice Address - Phone:956-607-8329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018011789235Z00000X
KS4056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist