Provider Demographics
NPI:1780073577
Name:FLANNERY, SAMANTHA MARIE (MS)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:FLANNERY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MARIE
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:501 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-1242
Mailing Address - Country:US
Mailing Address - Phone:815-227-8400
Mailing Address - Fax:815-229-2445
Practice Address - Street 1:501 7TH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1242
Practice Address - Country:US
Practice Address - Phone:815-227-8400
Practice Address - Fax:815-229-2445
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013576235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669860193Medicaid