Provider Demographics
NPI:1083278543
Name:ROGOZYNSKI, SAMANTHA NICOLE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:ROGOZYNSKI
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 MULLAN RD APT 203
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5558
Mailing Address - Country:US
Mailing Address - Phone:406-253-6721
Mailing Address - Fax:
Practice Address - Street 1:901 SW HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-3600
Practice Address - Country:US
Practice Address - Phone:406-253-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2022-08-19
Deactivation Date:2022-07-27
Deactivation Code:
Reactivation Date:2022-08-18
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MTOTP-OT-LIC-9458225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician