Provider Demographics
NPI:1235670167
Name:KELLEY, SAMANTHA (AT, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1732
Mailing Address - Country:US
Mailing Address - Phone:614-940-8678
Mailing Address - Fax:
Practice Address - Street 1:140 HILL ST STE B
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1566
Practice Address - Country:US
Practice Address - Phone:614-940-8678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0044812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer