Provider Demographics
NPI:1164164943
Name:ROTT, SAMANTHA KAITLYN MOORE
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:KAITLYN MOORE
Last Name:ROTT
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 1:8645 SE SUNNYBROOK BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6841
Mailing Address - Country:US
Mailing Address - Phone:503-708-0422
Mailing Address - Fax:
Practice Address - Street 1:15970 SE MISTY DR UNIT 100
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-4368
Practice Address - Country:US
Practice Address - Phone:503-427-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8410106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist