Provider Demographics
NPI:1114756830
Name:KOSS, SAMANTHA RAE (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:RAE
Last Name:KOSS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 21ST ST APT 379
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-3895
Mailing Address - Country:US
Mailing Address - Phone:814-691-4616
Mailing Address - Fax:
Practice Address - Street 1:1988 HAIRE RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8807
Practice Address - Country:US
Practice Address - Phone:803-548-9113
Practice Address - Fax:803-784-2313
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8421235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty