Provider Demographics
NPI:1073170791
Name:BARG, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BARG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1035 N. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868
Mailing Address - Country:US
Mailing Address - Phone:936-203-3328
Mailing Address - Fax:
Practice Address - Street 1:1035 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868
Practice Address - Country:US
Practice Address - Phone:936-203-3328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14662-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist