Provider Demographics
NPI:1053086686
Name:REZAC, SAMANTHA ROSE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:REZAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 GLADYS AVE
Mailing Address - Street 2:
Mailing Address - City:YUTAN
Mailing Address - State:NE
Mailing Address - Zip Code:68073-3014
Mailing Address - Country:US
Mailing Address - Phone:402-430-2005
Mailing Address - Fax:
Practice Address - Street 1:600 BROOKSTONE MEADOWS PLZ
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-4401
Practice Address - Country:US
Practice Address - Phone:402-289-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE901210225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist