Provider Demographics
NPI:1235788688
Name:KASPRZYK, SAMANTHA (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KASPRZYK
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:TRESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:2915 NORTH 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-779-1679
Mailing Address - Fax:928-779-2822
Practice Address - Street 1:NORTHLAND - RURAL THERAPY ASSOCIATES
Practice Address - Street 2:2915 NORTH 4TH STREET
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:928-779-2822
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-007908225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ578439Medicaid