Provider Demographics
NPI:1710363858
Name:SAMSON, STEPHANIE (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SAMSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 AVERY ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1005
Mailing Address - Country:US
Mailing Address - Phone:617-375-8644
Mailing Address - Fax:617-375-8581
Practice Address - Street 1:4 AVERY ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1005
Practice Address - Country:US
Practice Address - Phone:617-375-8644
Practice Address - Fax:617-375-8581
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400249305Medicare PIN