Provider Demographics
NPI:1982054839
Name:CONKLIN, SAMANTHA PAIGE (SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PAIGE
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 RANDOM LN
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9304
Mailing Address - Country:US
Mailing Address - Phone:989-732-3508
Mailing Address - Fax:
Practice Address - Street 1:508 RANDOM LN
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9304
Practice Address - Country:US
Practice Address - Phone:989-732-3508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005017235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist