Provider Demographics
NPI:1588998843
Name:TERRA, SAMANTHA (MS CCC-SLP/TSSLD)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:TERRA
Suffix:
Gender:F
Credentials:MS CCC-SLP/TSSLD
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:L
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:940B CLOVE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3611
Mailing Address - Country:US
Mailing Address - Phone:718-619-9602
Mailing Address - Fax:
Practice Address - Street 1:2929 W 30TH ST
Practice Address - Street 2:PS. 771K @ 329 - SPEECH DEPARTMENT
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1701
Practice Address - Country:US
Practice Address - Phone:718-787-3480
Practice Address - Fax:718-996-5095
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017923235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY163630049Medicaid