Healthcare Provider Details

I. General information

NPI: 1043123904
Provider Name (Legal Business Name): TRISELLE SAMUELS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 MONTGOMERY AVE
NARBERTH PA
19072-1937
US

IV. Provider business mailing address

2537 W GORDON ST
PHILADELPHIA PA
19132-4218
US

V. Phone/Fax

Practice location:
  • Phone: 215-618-2509
  • Fax:
Mailing address:
  • Phone: 973-220-0882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: