Healthcare Provider Details

I. General information

NPI: 1548759806
Provider Name (Legal Business Name): SAMANTHA MCCLOUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 1ST STREET
MADDOCK ND
58348
US

IV. Provider business mailing address

801 5TH AVE NE
DEVILS LAKE ND
58301-2202
US

V. Phone/Fax

Practice location:
  • Phone: 701-438-2531
  • Fax:
Mailing address:
  • Phone: 701-662-7690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number000425056
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1613
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: