Provider Demographics
NPI:1790083947
Name:MOHN, SAMANTHA ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:MOHN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ROSE
Other - Last Name:MOHN-JOHNSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 22499
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2499
Mailing Address - Country:US
Mailing Address - Phone:503-496-0385
Mailing Address - Fax:
Practice Address - Street 1:10600 SE MCLOUGHLIN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7428
Practice Address - Country:US
Practice Address - Phone:503-496-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05633174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist