Provider Demographics
NPI:1700236262
Name:MAZZUCCO, SAMANTHA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MAZZUCCO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:ANDAZOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1106 WALNUT ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2416
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:2560 E FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-1514
Practice Address - Country:US
Practice Address - Phone:520-323-9086
Practice Address - Fax:520-323-6364
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12230PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist