Provider Demographics
NPI:1144778549
Name:ROBERTSON, SAMANTHA (MED, EDS)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 BRIDGEPORT AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-4062
Mailing Address - Country:US
Mailing Address - Phone:330-718-9022
Mailing Address - Fax:
Practice Address - Street 1:420 WASHINGTON AVE.
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221
Practice Address - Country:US
Practice Address - Phone:330-718-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21316221390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program