Provider Demographics
NPI:1063933646
Name:WALCZAK, SAMANTHA JEAN (CFY-SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN
Last Name:WALCZAK
Suffix:
Gender:F
Credentials:CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13455 W FOUNTAIN DR APT 106
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-3996
Mailing Address - Country:US
Mailing Address - Phone:847-774-3391
Mailing Address - Fax:
Practice Address - Street 1:5404 W LOOMIS RD
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:WI
Practice Address - Zip Code:53129-1411
Practice Address - Country:US
Practice Address - Phone:414-421-0088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-04
Last Update Date:2017-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4479-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist