Provider Demographics
NPI:1427534551
Name:SCHALLERT, SAMANTHA LEE (PTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:SCHALLERT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7339 GERARDINI DR
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1326
Mailing Address - Country:US
Mailing Address - Phone:314-807-3580
Mailing Address - Fax:
Practice Address - Street 1:7339 GERARDINI DR
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1326
Practice Address - Country:US
Practice Address - Phone:314-807-3580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041.0133893225200000X
MO2017025112225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant