Provider Demographics
NPI:1609248780
Name:DAVIS, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DAVIS
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 1:1018 PINE ST
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1139
Mailing Address - Country:US
Mailing Address - Phone:608-279-9322
Mailing Address - Fax:
Practice Address - Street 1:286 ROSE ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53508-9207
Practice Address - Country:US
Practice Address - Phone:608-843-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5779 - 26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist