Provider Demographics
NPI:1891021648
Name:ELETZ, SAMANTHA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ELETZ
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 1:512 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-1030
Mailing Address - Country:US
Mailing Address - Phone:215-740-6113
Mailing Address - Fax:
Practice Address - Street 1:512 CARROLL ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-1030
Practice Address - Country:US
Practice Address - Phone:215-740-6113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017520-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY017520OtherSPEECH LICENSE NUMBER