Provider Demographics
NPI:1841604824
Name:SAMUELS, ELISA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15010 71ST AVE
Mailing Address - Street 2:APT. 4B
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2143
Mailing Address - Country:US
Mailing Address - Phone:516-398-5635
Mailing Address - Fax:
Practice Address - Street 1:15010 71ST AVE
Practice Address - Street 2:APT. 4B
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-2143
Practice Address - Country:US
Practice Address - Phone:516-398-5635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2016-11-30
Deactivation Date:2015-06-30
Deactivation Code:
Reactivation Date:2016-11-30
Provider Licenses
StateLicense IDTaxonomies
NY021281235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist