Provider Demographics
NPI:1730424029
Name:SAMANTA, NIRMAL K (PHD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:NIRMAL
Middle Name:K
Last Name:SAMANTA
Suffix:
Gender:M
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BRANDY LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-8443
Mailing Address - Country:US
Mailing Address - Phone:573-450-3393
Mailing Address - Fax:573-339-0911
Practice Address - Street 1:500 CARLSON PKWY
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5304
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3531235Z00000X
MO2004016682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist