Provider Demographics
NPI:1477057313
Name:NOVAK, SAMANTHA KAE (DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KAE
Last Name:NOVAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:KAE
Other - Last Name:ROBERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1892 E CHIPPEWA RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-8206
Mailing Address - Country:US
Mailing Address - Phone:989-600-7433
Mailing Address - Fax:
Practice Address - Street 1:3615 E ASHMAN ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-8858
Practice Address - Country:US
Practice Address - Phone:989-631-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5501017017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist