MEDICARE: SAMANTHA BLONDELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	028258	NY

General Provider Information

NPI Number	:	1003382714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA BLONDELL

Provider Business Mailing Address
First Line	:	4809 CENTER BLVD
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11109-5605
Country	:	US
Telephone Number	:	718-392-5402
Fax Number	:

Provider Business Practice Location Address
First Line	:	4809 CENTER BLVD
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11109-5605
Country	:	US
Telephone Number	:	718-392-5402
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2018
Last Update Date	:	10/19/2018

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Directions to “ SAMANTHA BLONDELL ” Practice Location

Language	Start Address	Practice Location

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