Provider Demographics
NPI:1699593210
Name:SAM, STEPHANY
Entity type:Individual
Prefix:
First Name:STEPHANY
Middle Name:
Last Name:SAM
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 1:2257 HEATHERDALE DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-5878
Mailing Address - Country:US
Mailing Address - Phone:469-422-4490
Mailing Address - Fax:
Practice Address - Street 1:5855 MILTON ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-4202
Practice Address - Country:US
Practice Address - Phone:214-361-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121460235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist