Provider Demographics
NPI:1316458821
Name:WALLENSTEIN, SAMANTHA (AUD,CCC-A)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WALLENSTEIN
Suffix:
Gender:F
Credentials:AUD,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 W CLINCH AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2287
Mailing Address - Country:US
Mailing Address - Phone:865-521-6005
Mailing Address - Fax:
Practice Address - Street 1:9546 S NORTHSHORE DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-5813
Practice Address - Country:US
Practice Address - Phone:865-521-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNA1746231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist