Provider Demographics
NPI:1265178206
Name:SHANK, SAMANTHA J
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:SHANK
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 1:115 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2802
Mailing Address - Country:US
Mailing Address - Phone:203-916-3243
Mailing Address - Fax:
Practice Address - Street 1:3036 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5733
Practice Address - Country:US
Practice Address - Phone:718-823-3190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist