Provider Demographics
NPI:1225673551
Name:JOHNSON, SAMARA DAEVA JOY (ATC)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:DAEVA JOY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ROYCE DR
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14428-8900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 ROYCE DR
Practice Address - Street 2:
Practice Address - City:CHURCHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14428-8900
Practice Address - Country:US
Practice Address - Phone:716-986-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC27732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program