Healthcare Provider Details

I. General information

NPI: 1972420552
Provider Name (Legal Business Name): SAMANTHA FORTAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 PILOT SCHOOL RD
THOMASVILLE NC
27360-0058
US

IV. Provider business mailing address

184 HIGH ST STE 701
BOSTON MA
02110-3025
US

V. Phone/Fax

Practice location:
  • Phone: 336-472-7965
  • Fax:
Mailing address:
  • Phone: 800-337-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30004528
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: