Provider Demographics
NPI:1366681108
Name:SAM, KATIE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:MARIE
Last Name:SAM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4961
Mailing Address - Country:US
Mailing Address - Phone:262-521-0028
Mailing Address - Fax:
Practice Address - Street 1:411 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4961
Practice Address - Country:US
Practice Address - Phone:262-521-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4581-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor