Provider Demographics
NPI:1336518984
Name:ZICKEFOOSE, SAMANTHA WREN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:WREN
Last Name:ZICKEFOOSE
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 1:3822 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-2319
Mailing Address - Country:US
Mailing Address - Phone:402-612-9468
Mailing Address - Fax:
Practice Address - Street 1:3822 CHICAGO ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-2319
Practice Address - Country:US
Practice Address - Phone:402-612-9468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12131266235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist