Provider Demographics
NPI:1922400183
Name:MARSH, SAMANTHA JOY (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JOY
Last Name:MARSH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:JOY
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CF SLP
Mailing Address - Street 1:5305 EAGLES WAY
Mailing Address - Street 2:APT 8
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-7382
Mailing Address - Country:US
Mailing Address - Phone:989-423-8785
Mailing Address - Fax:
Practice Address - Street 1:1525 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6425
Practice Address - Country:US
Practice Address - Phone:989-835-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001058235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7101001058OtherSTATE OF MICHIGAN