Provider Demographics
NPI:1255046678
Name:WONG, SAMANTHA KIMBERLY (CF-SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KIMBERLY
Last Name:WONG
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5723
Mailing Address - Country:US
Mailing Address - Phone:215-796-3906
Mailing Address - Fax:
Practice Address - Street 1:3 COOPER PLZ RM 511
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1407
Practice Address - Country:US
Practice Address - Phone:856-342-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ4044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist