Provider Demographics
NPI:1548742398
Name:SMITH, SAMANTHA BLAIRE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:BLAIRE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 TENNYSON AVE NE
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2600
Mailing Address - Country:US
Mailing Address - Phone:330-844-1391
Mailing Address - Fax:
Practice Address - Street 1:1946 TENNYSON AVE NE
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-2600
Practice Address - Country:US
Practice Address - Phone:330-844-1391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer