Provider Demographics
NPI:1508344334
Name:SAMUELSON, VICTORIA JOY (PTA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JOY
Last Name:SAMUELSON
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 1:553 ROCKY POINT RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-9726
Mailing Address - Country:US
Mailing Address - Phone:501-733-9629
Mailing Address - Fax:
Practice Address - Street 1:915 W EXCHANGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-7018
Practice Address - Country:US
Practice Address - Phone:214-547-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2140302225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant