Provider Demographics
NPI:1629544549
Name:WATSON, SAMANTHA LESLEY (PT, DPT, MBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LESLEY
Last Name:WATSON
Suffix:
Gender:F
Credentials:PT, DPT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-8801
Mailing Address - Country:US
Mailing Address - Phone:910-298-6455
Mailing Address - Fax:910-298-6405
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2575
Practice Address - Country:US
Practice Address - Phone:607-624-8607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist