Provider Demographics
NPI:1225545148
Name:SAMPSON, MICHAEL RICHARD (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RICHARD
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 WALNUT TREE HILL RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-2046
Mailing Address - Country:US
Mailing Address - Phone:203-395-6993
Mailing Address - Fax:
Practice Address - Street 1:61 N PLAINS INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-5841
Practice Address - Country:US
Practice Address - Phone:860-805-7259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-30
Last Update Date:2017-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer