Provider Demographics
NPI:1962819805
Name:GIBLIN, SAMANTHA C (LMT# 19906)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:C
Last Name:GIBLIN
Suffix:
Gender:F
Credentials:LMT# 19906
Other - Prefix:
Other - First Name:CHESTINA
Other - Middle Name:SAMANTHA
Other - Last Name:RUTLEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT# 19906
Mailing Address - Street 1:4403 VASEND CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-4713
Mailing Address - Country:US
Mailing Address - Phone:506-602-2844
Mailing Address - Fax:
Practice Address - Street 1:960 LIBERTY ST SE STE 170
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4149
Practice Address - Country:US
Practice Address - Phone:503-588-6633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19906225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR19906OtherMASSAGE LICENSE