Provider Demographics
NPI:1245013200
Name:WISECARVER, SAMANTHA RENEE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:WISECARVER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 NE 8TH AVE APT A
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-5751
Mailing Address - Country:US
Mailing Address - Phone:813-600-8508
Mailing Address - Fax:
Practice Address - Street 1:2792 DONNELLY DR
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-6431
Practice Address - Country:US
Practice Address - Phone:888-725-2987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19469235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist