Provider Demographics
NPI:1497244040
Name:FERNHOLZ, SAMANTHA (MS, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FERNHOLZ
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 DUSTIR DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-1577
Mailing Address - Country:US
Mailing Address - Phone:262-664-1024
Mailing Address - Fax:
Practice Address - Street 1:3535 W SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4479
Practice Address - Country:US
Practice Address - Phone:262-664-1024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X2255A2300X
OHAT0060142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer