Provider Demographics
NPI:1154959484
Name:FANTIN, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FANTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4524 N WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-2052
Mailing Address - Country:US
Mailing Address - Phone:509-903-5483
Mailing Address - Fax:
Practice Address - Street 1:4524 N WINDSOR DR
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-2052
Practice Address - Country:US
Practice Address - Phone:509-903-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2023-07-24
Deactivation Date:2020-04-02
Deactivation Code:
Reactivation Date:2020-07-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASI61064749OtherSLP
WA1154959484OtherSLP