Provider Demographics
NPI:1053042432
Name:ANTONACCI, SAMUEL JUSTIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JUSTIN
Last Name:ANTONACCI
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12775 BEECH ST NE
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-8778
Mailing Address - Country:US
Mailing Address - Phone:330-904-4130
Mailing Address - Fax:
Practice Address - Street 1:6057 STRIP AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-9207
Practice Address - Country:US
Practice Address - Phone:330-492-8136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT018270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist