Provider Demographics
NPI:1750782108
Name:SAMUELSON, KATIE CARLEEN (MA, CCC- SLP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:CARLEEN
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:MA, CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 OCONNOR RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1327
Mailing Address - Country:US
Mailing Address - Phone:585-383-2216
Mailing Address - Fax:585-383-6679
Practice Address - Street 1:41 OCONNOR RD
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1327
Practice Address - Country:US
Practice Address - Phone:585-383-2216
Practice Address - Fax:585-383-6679
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023438-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355344Medicaid
NY336527Medicare UPIN