Provider Demographics
NPI:1750650768
Name:MATTOX, SAMUEL TRAVIS (OTR L)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:TRAVIS
Last Name:MATTOX
Suffix:
Gender:M
Credentials:OTR L
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Mailing Address - Street 1:1483 TOBIAS GADSON BLVD
Mailing Address - Street 2:SUITE 205B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4641
Mailing Address - Country:US
Mailing Address - Phone:843-766-6494
Mailing Address - Fax:843-766-6495
Practice Address - Street 1:100 HEALTHY WAY
Practice Address - Street 2:SUITE 1110
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-7915
Practice Address - Country:US
Practice Address - Phone:864-261-3099
Practice Address - Fax:864-261-6617
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2016-01-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC3437225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ41045Medicare PIN