Provider Demographics
NPI:1508418930
Name:SULLIVAN, SAMANTHA JEAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:JEAN
Other - Last Name:FOREHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:5627 NW 86TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1738
Mailing Address - Country:US
Mailing Address - Phone:515-270-0303
Mailing Address - Fax:515-270-0160
Practice Address - Street 1:5627 NW 86TH ST STE 200
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1738
Practice Address - Country:US
Practice Address - Phone:515-270-0303
Practice Address - Fax:515-270-0160
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist