Provider Demographics
NPI:1760965412
Name:SECRIST, SAMANTHA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SECRIST
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8817 WESTWARD WAY
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-6905
Mailing Address - Country:US
Mailing Address - Phone:614-329-9085
Mailing Address - Fax:
Practice Address - Street 1:8817 WESTWARD WAY
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-6905
Practice Address - Country:US
Practice Address - Phone:614-329-9085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2024-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094740Medicaid