Provider Demographics
NPI:1194099838
Name:SAMPLE, SHALAINA NICOLE (MS CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:SHALAINA
Middle Name:NICOLE
Last Name:SAMPLE
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 1:6130 N FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-1335
Mailing Address - Country:US
Mailing Address - Phone:267-879-2541
Mailing Address - Fax:
Practice Address - Street 1:6130 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1335
Practice Address - Country:US
Practice Address - Phone:267-879-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SL010589235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist