Healthcare Provider Details

I. General information

NPI: 1497482004
Provider Name (Legal Business Name): SAMANTHA GUMULA M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date: 07/28/2024
Reactivation Date: 09/08/2025

III. Provider practice location address

343 PRADO WAY
GREENVILLE SC
29607-6512
US

IV. Provider business mailing address

1405 LEANING TOWER CT
SIMPSONVILLE SC
29680-7588
US

V. Phone/Fax

Practice location:
  • Phone: 864-270-8647
  • Fax:
Mailing address:
  • Phone: 561-767-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8778
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: