Provider Demographics
NPI:1861901845
Name:MALAKOOTI, SAMIRA (MA)
Entity type:Individual
Prefix:
First Name:SAMIRA
Middle Name:
Last Name:MALAKOOTI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5437 OLDE DUBLIN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-3204
Mailing Address - Country:US
Mailing Address - Phone:330-219-2154
Mailing Address - Fax:
Practice Address - Street 1:3805 MARLANE DR
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9224
Practice Address - Country:US
Practice Address - Phone:614-801-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2017215235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty