Healthcare Provider Details

I. General information

NPI: 1053249037
Provider Name (Legal Business Name): SAMANTHA DEBAUCHE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4578 PAUL LN
GREEN BAY WI
54313-2409
US

IV. Provider business mailing address

4578 PAUL LN
GREEN BAY WI
54313-2409
US

V. Phone/Fax

Practice location:
  • Phone: 920-481-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: