Provider Demographics
NPI:1033599543
Name:NOVOTNY, SAMANTHA JO (DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:NOVOTNY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:MOSER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-0435
Mailing Address - Country:US
Mailing Address - Phone:605-842-7188
Mailing Address - Fax:605-842-7189
Practice Address - Street 1:825 E 8TH ST.
Practice Address - Street 2:SUITE 204
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-2633
Practice Address - Country:US
Practice Address - Phone:605-842-7188
Practice Address - Fax:605-842-7189
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1033599543Medicaid
SDS109445Medicare PIN