Provider Demographics
NPI:1255648341
Name:SAMUELS, MARY T (SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:T
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:SAUQUOIT
Mailing Address - State:NY
Mailing Address - Zip Code:13456-2916
Mailing Address - Country:US
Mailing Address - Phone:315-737-8240
Mailing Address - Fax:
Practice Address - Street 1:106 MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4818
Practice Address - Country:US
Practice Address - Phone:315-368-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002818-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist