Provider Demographics
NPI:1396282422
Name:FARBER, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FARBER
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 1:130 RED COACH DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3144
Mailing Address - Country:US
Mailing Address - Phone:574-387-4313
Mailing Address - Fax:
Practice Address - Street 1:1595 S CALUMET RD
Practice Address - Street 2:SUITE #3
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2388
Practice Address - Country:US
Practice Address - Phone:844-896-0235
Practice Address - Fax:219-898-4258
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IN46003103A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196020AMedicaid