Provider Demographics
NPI:1184029548
Name:MORETTI, SAMANTHA JO (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:MORETTI
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 S LOMBARD RD
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-2566
Mailing Address - Country:US
Mailing Address - Phone:630-935-5953
Mailing Address - Fax:
Practice Address - Street 1:412 S LOMBARD RD
Practice Address - Street 2:
Practice Address - City:ITASCA
Practice Address - State:IL
Practice Address - Zip Code:60143-2566
Practice Address - Country:US
Practice Address - Phone:630-935-5953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010812225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist