Healthcare Provider Details

I. General information

NPI: 1477825503
Provider Name (Legal Business Name): MRS. SAMANTHA LYNN DALLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S IRONWOOD DR
APACHE JUNCTION AZ
85120-5002
US

IV. Provider business mailing address

2024 S BALDWIN UNIT 36
MESA AZ
85209-1704
US

V. Phone/Fax

Practice location:
  • Phone: 480-677-7520
  • Fax: 480-982-4978
Mailing address:
  • Phone: 480-677-7520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License NumberSLPA7012
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: