Provider Demographics
NPI:1104233840
Name:BARKSDALE, SAMANTHA (MS, CF-SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BARKSDALE
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 HOLMES PITTMAN RD
Mailing Address - Street 2:
Mailing Address - City:FOXWORTH
Mailing Address - State:MS
Mailing Address - Zip Code:39483-3166
Mailing Address - Country:US
Mailing Address - Phone:601-736-3111
Mailing Address - Fax:601-444-5036
Practice Address - Street 1:285 HOLMES PITTMAN RD
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-3166
Practice Address - Country:US
Practice Address - Phone:601-736-3111
Practice Address - Fax:601-444-5036
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS3869OtherMISSISSIPPI STATE BOARD OF HEALTH LICENSE