Provider Demographics
NPI:1639700669
Name:JOHNSON, SAMANTHA ODESSA (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ODESSA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 E TANQUE VERDE RD APT 4203
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85749-7707
Mailing Address - Country:US
Mailing Address - Phone:740-497-3100
Mailing Address - Fax:
Practice Address - Street 1:707 N ALVERNON WAY STE 203
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1847
Practice Address - Country:US
Practice Address - Phone:520-462-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30213208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation