=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306302484
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA RAE COONTZ MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2019
-----------------------------------------------------
Last Update Date | 02/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 S CONROE MEDICAL DR
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-494-6600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12107 NORMONT DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-517-5199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 113361
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------