Provider Demographics
NPI:1821439019
Name:OLIVER, SAMANTHA JO (PT, DPT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:JO
Last Name:OLIVER
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:HENSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5255 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2637
Mailing Address - Country:US
Mailing Address - Phone:208-338-9486
Mailing Address - Fax:208-338-0171
Practice Address - Street 1:5255 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2637
Practice Address - Country:US
Practice Address - Phone:208-338-9486
Practice Address - Fax:208-338-0171
Is Sole Proprietor?:No
Enumeration Date:2013-07-16
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3318225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist