Healthcare Provider Details

I. General information

NPI: 1114756830
Provider Name (Legal Business Name): SAMANTHA RAE KOSS MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11940 CAROLINA PLACE PKWY STE 200
PINEVILLE NC
28134-7471
US

IV. Provider business mailing address

3528 ENFIELD RD
CHARLOTTE NC
28205-4408
US

V. Phone/Fax

Practice location:
  • Phone: 704-541-9080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30005011
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: