Provider Demographics
NPI:1306448535
Name:MCCRAVY BRYANT, SAMANTHA CHRISTINE (SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CHRISTINE
Last Name:MCCRAVY BRYANT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:CHRISTINE MCCRAVY
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:1268 EDGEWOOD AVE S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-7744
Mailing Address - Country:US
Mailing Address - Phone:904-575-0643
Mailing Address - Fax:
Practice Address - Street 1:1268 EDGEWOOD AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7744
Practice Address - Country:US
Practice Address - Phone:904-575-0643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18072235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist