Provider Demographics
NPI:1942812128
Name:KHEBOIAN, SAMANTHA NORMAN (LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:NORMAN
Last Name:KHEBOIAN
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:KATE
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:71 LAKESHORE AVE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1907
Mailing Address - Country:US
Mailing Address - Phone:781-760-2769
Mailing Address - Fax:
Practice Address - Street 1:71 LAKESHORE AVE
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1907
Practice Address - Country:US
Practice Address - Phone:781-760-2769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA25332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer