Provider Demographics
NPI:1801192752
Name:SAMUELS, KHADEISHA KASHEMA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KHADEISHA
Middle Name:KASHEMA
Last Name:SAMUELS
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 1:790 6TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4013
Mailing Address - Country:US
Mailing Address - Phone:863-229-8319
Mailing Address - Fax:
Practice Address - Street 1:790 6TH ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4013
Practice Address - Country:US
Practice Address - Phone:863-229-8319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 5049235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSZ 5049OtherPROVISIONAL SPEECH-LANGUAGE PATHOLOGIST