Provider Demographics
NPI:1639467012
Name:MODDERMAN, SAMANTHA JO (PT,DPT)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JO
Last Name:MODDERMAN
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 WHITEFISH STAGE ROAD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2753
Mailing Address - Country:US
Mailing Address - Phone:406-756-7878
Mailing Address - Fax:406-257-7811
Practice Address - Street 1:1234 WHITEFISH STAGE
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2753
Practice Address - Country:US
Practice Address - Phone:406-756-7878
Practice Address - Fax:406-257-7811
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2439225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist