Provider Demographics
NPI:1013674803
Name:GIPSON, SAMANTHA BROOKE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:BROOKE
Last Name:GIPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3146 HIGHWAY 148
Mailing Address - Street 2:
Mailing Address - City:MONETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72447-9118
Mailing Address - Country:US
Mailing Address - Phone:870-530-6246
Mailing Address - Fax:
Practice Address - Street 1:151 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5828
Practice Address - Country:US
Practice Address - Phone:870-932-0090
Practice Address - Fax:870-930-9336
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTA1783224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant