Provider Demographics
NPI:1962913871
Name:CLARK, SAMANTHA (SLP)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9325 MIDLOTHIAN TPKE STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4943
Mailing Address - Country:US
Mailing Address - Phone:757-490-3223
Mailing Address - Fax:757-490-2936
Practice Address - Street 1:9325 MIDLOTHIAN TPKE STE A
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4943
Practice Address - Country:US
Practice Address - Phone:757-490-3223
Practice Address - Fax:757-490-2936
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006809235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist