Provider Demographics
NPI:1316397789
Name:KING, SAMANTHA JOELLE (DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOELLE
Last Name:KING
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 HIGHWAY 81
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9138
Mailing Address - Country:US
Mailing Address - Phone:770-554-0665
Mailing Address - Fax:770-554-0685
Practice Address - Street 1:620 W MACPHAIL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4474
Practice Address - Country:US
Practice Address - Phone:410-399-9590
Practice Address - Fax:410-399-9591
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25997225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist