Provider Demographics
NPI:1164017927
Name:BAGNATO, SAMANTHA HERRELL (OTR/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:HERRELL
Last Name:BAGNATO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7315 MENDOTA AVE
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1413
Mailing Address - Country:US
Mailing Address - Phone:540-533-7006
Mailing Address - Fax:
Practice Address - Street 1:2235 TACKETTS MILL DR # C
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3036
Practice Address - Country:US
Practice Address - Phone:703-491-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008524225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics