Provider Demographics
NPI:1265849988
Name:DOVERSPIKE, SAMANTHA M (DPT)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:M
Last Name:DOVERSPIKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:M
Other - Last Name:PICKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 11629
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59719-1629
Mailing Address - Country:US
Mailing Address - Phone:406-522-7488
Mailing Address - Fax:406-522-7487
Practice Address - Street 1:47 PRONGHORN TRAIL SITE #1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6096
Practice Address - Country:US
Practice Address - Phone:406-585-9044
Practice Address - Fax:406-585-9220
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MT19369225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400163462Medicare PIN