Provider Demographics
NPI:1467633628
Name:SAMPSON, ANGELA TISE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:TISE
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 VANCOUVER CT
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-9256
Mailing Address - Country:US
Mailing Address - Phone:336-996-4744
Mailing Address - Fax:336-996-4745
Practice Address - Street 1:187 VANCOUVER CT
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-9256
Practice Address - Country:US
Practice Address - Phone:336-996-4744
Practice Address - Fax:336-996-4745
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3990225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1217FOtherBCBS
NCD0591OtherMEDCOST
NC7301309Medicaid