Provider Demographics
NPI:1871006874
Name:VAILLANCOURT, SAMANTHA LYNN (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LYNN
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5400 NW 39TH AVE APT M104
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6951
Mailing Address - Country:US
Mailing Address - Phone:810-886-2243
Mailing Address - Fax:
Practice Address - Street 1:4907 NW 43RD ST STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-2007
Practice Address - Country:US
Practice Address - Phone:352-372-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11737235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist