Provider Demographics
NPI:1972109791
Name:HASSAN, SAMY BAHER
Entity Type:Individual
Prefix:
First Name:SAMY
Middle Name:BAHER
Last Name:HASSAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1398 MEADOWBROOK RD NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5045
Mailing Address - Country:US
Mailing Address - Phone:321-412-8230
Mailing Address - Fax:
Practice Address - Street 1:1398 MEADOWBROOK RD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5045
Practice Address - Country:US
Practice Address - Phone:321-412-8230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20301225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty