Provider Demographics
NPI:1003589318
Name:PORTER, SAMANTHA R (PT, DPT, LMT, CMTPT)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:R
Last Name:PORTER
Suffix:
Gender:F
Credentials:PT, DPT, LMT, CMTPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 STATESMAN CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10407 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:FRONTENAC
Practice Address - State:MO
Practice Address - Zip Code:63131-2909
Practice Address - Country:US
Practice Address - Phone:314-432-6103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210305382251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic