Provider Demographics
NPI:1114275732
Name:POWELL, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5691 SE HULL ST
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-2406
Mailing Address - Country:US
Mailing Address - Phone:772-595-4858
Mailing Address - Fax:
Practice Address - Street 1:2684 SW IMMANUEL DR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2738
Practice Address - Country:US
Practice Address - Phone:772-291-2179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT25129225X00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator