Provider Demographics
NPI:1891083390
Name:HAGNESS, SAMANTHA LEIGH
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEIGH
Last Name:HAGNESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 W GROVE PKWY
Mailing Address - Street 2:APT #2120
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-8440
Mailing Address - Country:US
Mailing Address - Phone:520-909-5240
Mailing Address - Fax:
Practice Address - Street 1:16428 E KINGSTREE BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-5440
Practice Address - Country:US
Practice Address - Phone:480-837-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP7334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist