Provider Demographics
NPI:1336505734
Name:PICO, SAMANTHA KATHERINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KATHERINE
Last Name:PICO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:KATHERINE
Other - Last Name:STADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:981 RTE 22 FL 2
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2946
Mailing Address - Country:US
Mailing Address - Phone:201-801-7141
Mailing Address - Fax:
Practice Address - Street 1:4056 QUAKERBRIDGE RD STE 108
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4779
Practice Address - Country:US
Practice Address - Phone:201-801-7141
Practice Address - Fax:732-218-5322
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60575553225100000X
NJ40QA01956700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist