Provider Demographics
NPI:1285913061
Name:DUBACH, SAMANTHA JO (BA, SLPA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JO
Last Name:DUBACH
Suffix:
Gender:F
Credentials:BA, SLPA
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA, SLPA
Mailing Address - Street 1:2109 NORMANDY DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-2445
Mailing Address - Country:US
Mailing Address - Phone:870-995-5089
Mailing Address - Fax:
Practice Address - Street 1:1700 COMMERCE BLVD.
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-2445
Practice Address - Country:US
Practice Address - Phone:870-995-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11-0032355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR187291721Medicaid