Provider Demographics
NPI:1639622582
Name:SZOSTAK, SAMANTHA L (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:SZOSTAK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:L
Other - Last Name:BRUGGEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:4301 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2503
Mailing Address - Country:US
Mailing Address - Phone:304-720-9185
Mailing Address - Fax:304-720-9186
Practice Address - Street 1:4301 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2503
Practice Address - Country:US
Practice Address - Phone:304-720-9185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210468225100000X
WV004094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1639622582OtherMEDICAID QMB ONLY
VAQ54163AMedicare PIN