Provider Demographics
NPI:1083984462
Name:WHEELOCK, SAMANTHA JOANNE (LPTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOANNE
Last Name:WHEELOCK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:MN
Mailing Address - Zip Code:55005
Mailing Address - Country:US
Mailing Address - Phone:763-269-8051
Mailing Address - Fax:
Practice Address - Street 1:139 MAIN ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:MN
Practice Address - Zip Code:55005-0136
Practice Address - Country:US
Practice Address - Phone:763-269-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1350225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant