Provider Demographics
NPI:1982230793
Name:EBANKS, SAMANTHA RIGGS (PTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RIGGS
Last Name:EBANKS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:NICOLE
Other - Last Name:RIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:182 S PINEHURST AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7648
Mailing Address - Country:US
Mailing Address - Phone:803-287-8821
Mailing Address - Fax:
Practice Address - Street 1:903 JORDAN BLASS DR STE 104
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-1325
Practice Address - Country:US
Practice Address - Phone:803-287-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-08-26
Deactivation Date:2020-08-13
Deactivation Code:
Reactivation Date:2020-08-26
Provider Licenses
StateLicense IDTaxonomies
FL30140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant