Provider Demographics
NPI:1083249833
Name:SAGRAVES, SAMANTHA M (PTA)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:M
Last Name:SAGRAVES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 N MT AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2171
Mailing Address - Country:US
Mailing Address - Phone:513-335-7868
Mailing Address - Fax:513-335-8193
Practice Address - Street 1:1405 N MT AUBURN RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2171
Practice Address - Country:US
Practice Address - Phone:513-335-7868
Practice Address - Fax:513-335-8193
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018009784225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant