Provider Demographics
NPI:1346705936
Name:BRADY, SAMANTHA L (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:L
Last Name:BRADY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 S AVENUE C
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7207
Mailing Address - Country:US
Mailing Address - Phone:505-228-2049
Mailing Address - Fax:
Practice Address - Street 1:2217 DILLON RD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-9454
Practice Address - Country:US
Practice Address - Phone:575-769-7356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist