Provider Demographics
NPI:1043869977
Name:HIGGERSON, SAMANTHA LAINE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LAINE
Last Name:HIGGERSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 S KINGSHIGHWAY ST # 1700
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-1695
Mailing Address - Country:US
Mailing Address - Phone:618-477-1676
Mailing Address - Fax:
Practice Address - Street 1:209 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-1695
Practice Address - Country:US
Practice Address - Phone:618-477-1676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0052262255A2300X
390200000X
MO20200311432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program