Provider Demographics
NPI:1558711663
Name:SAMS, BERNETTA
Entity Type:Individual
Prefix:
First Name:BERNETTA
Middle Name:
Last Name:SAMS
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 1:356 FERRIS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-5002
Mailing Address - Country:US
Mailing Address - Phone:304-667-2369
Mailing Address - Fax:
Practice Address - Street 1:203 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1316
Practice Address - Country:US
Practice Address - Phone:304-667-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2001-0689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist