Healthcare Provider Details

I. General information

NPI: 1568115723
Provider Name (Legal Business Name): SAMANTHA PRAZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 11TH AVE S STE 155
NAMPA ID
83651-3946
US

IV. Provider business mailing address

7108 S KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-1077
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: