Provider Demographics
NPI:1669894259
Name:FOGARAZZO, SAMANTHA MARY
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARY
Last Name:FOGARAZZO
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 1:93 LOUSIANA STREET
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-3711
Mailing Address - Country:US
Mailing Address - Phone:516-476-3837
Mailing Address - Fax:
Practice Address - Street 1:750 CLASSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-4607
Practice Address - Country:US
Practice Address - Phone:718-638-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist