Provider Demographics
NPI:1083377105
Name:MCISAAC, SAMANTHA (DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MCISAAC
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 104T AVE SW
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-9032
Mailing Address - Country:US
Mailing Address - Phone:701-690-1216
Mailing Address - Fax:
Practice Address - Street 1:1595 GRAND AVE STE 265
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-3072
Practice Address - Country:US
Practice Address - Phone:406-371-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-17174225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist