Provider Demographics
NPI:1851627772
Name:SAMALOT, DIANA (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:SAMALOT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 NW BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1007
Mailing Address - Country:US
Mailing Address - Phone:772-879-0713
Mailing Address - Fax:
Practice Address - Street 1:527 NW CASHMERE BLVD
Practice Address - Street 2:UNIT 103
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1959
Practice Address - Country:US
Practice Address - Phone:772-204-9822
Practice Address - Fax:772-336-9932
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA177235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist