Provider Demographics
NPI:1639417769
Name:MILLER, SAMANTHA RAE (COTA/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:MILLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RAE
Other - Last Name:MIELITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:40587 116TH ST
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:SD
Mailing Address - Zip Code:57449-6610
Mailing Address - Country:US
Mailing Address - Phone:605-290-5310
Mailing Address - Fax:
Practice Address - Street 1:410 2ND STREET
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:SD
Practice Address - Zip Code:57219-0337
Practice Address - Country:US
Practice Address - Phone:605-492-3615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD258A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant