Provider Demographics
NPI:1790459295
Name:AYALA, SAMANTHA ANGELICA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANGELICA
Last Name:AYALA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-2912
Mailing Address - Country:US
Mailing Address - Phone:201-618-9041
Mailing Address - Fax:
Practice Address - Street 1:726 BROADWAY FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9616
Practice Address - Country:US
Practice Address - Phone:201-618-9041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-06
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS01087600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist