Provider Demographics
NPI:1245741198
Name:CROW, SAMANTHA JANE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JANE
Last Name:CROW
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 N VILLA LAKE DR APT P1
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-8265
Mailing Address - Country:US
Mailing Address - Phone:309-410-7814
Mailing Address - Fax:
Practice Address - Street 1:701 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61531-1460
Practice Address - Country:US
Practice Address - Phone:309-245-2407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.011814225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist