Provider Demographics
NPI:1245580687
Name:KOTTKE, SAMANTHA CHRISTINE (LMP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CHRISTINE
Last Name:KOTTKE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 NW CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370
Mailing Address - Country:US
Mailing Address - Phone:360-434-2026
Mailing Address - Fax:
Practice Address - Street 1:25960 OHIO AVE SUITE 206
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346
Practice Address - Country:US
Practice Address - Phone:360-434-2026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60297577225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist