Provider Demographics
NPI:1619568540
Name:ORTOLANO, SAMANTHA MARIE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:ORTOLANO
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 1:590 N ATLANTIC AVE APT 313
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-3427
Mailing Address - Country:US
Mailing Address - Phone:215-510-8784
Mailing Address - Fax:
Practice Address - Street 1:212 MARTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3114
Practice Address - Country:US
Practice Address - Phone:856-291-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09201400224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJO76366877456884OtherDRIVERS LICENSE