Provider Demographics
NPI:1629566252
Name:POLSON, SAMANTHA M
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:POLSON
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 1:731 ANTIOCH CIR N
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-9465
Mailing Address - Country:US
Mailing Address - Phone:708-717-5017
Mailing Address - Fax:812-237-9612
Practice Address - Street 1:567 N 5TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-1903
Practice Address - Country:US
Practice Address - Phone:708-717-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer