Provider Demographics
NPI:1649517004
Name:WOLTERS, SAMANTHA (MED)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:WOLTERS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-1157
Mailing Address - Country:US
Mailing Address - Phone:412-414-1986
Mailing Address - Fax:
Practice Address - Street 1:87 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1157
Practice Address - Country:US
Practice Address - Phone:412-414-1986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT00108L231H00000X
PAPDE 1673236235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist