Provider Demographics
NPI:1902910300
Name:SAMPLES, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SAMPLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 HWY 61
Mailing Address - Street 2:
Mailing Address - City:PORTAGEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63873
Mailing Address - Country:US
Mailing Address - Phone:573-379-0357
Mailing Address - Fax:
Practice Address - Street 1:904 KING AVE
Practice Address - Street 2:
Practice Address - City:PORTAGEVILLE
Practice Address - State:MO
Practice Address - Zip Code:63873-1378
Practice Address - Country:US
Practice Address - Phone:573-379-5706
Practice Address - Fax:573-379-5873
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2057235Z00000X
MO107513235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X378Medicare UPIN