Provider Demographics
NPI:1518390400
Name:SAMUELSON, COREY R (DPT)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:R
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:MA
Mailing Address - Zip Code:02766-2436
Mailing Address - Country:US
Mailing Address - Phone:508-285-4155
Mailing Address - Fax:508-285-4483
Practice Address - Street 1:250 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:MA
Practice Address - Zip Code:02766-2436
Practice Address - Country:US
Practice Address - Phone:508-285-5533
Practice Address - Fax:508-285-4483
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist