Provider Demographics
NPI:1023418142
Name:HENDERSON, SAMANTHA L (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:L
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 COMMONWEALTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-4526
Mailing Address - Country:US
Mailing Address - Phone:330-760-3576
Mailing Address - Fax:
Practice Address - Street 1:3057 CLEVELAND AVE SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-3625
Practice Address - Country:US
Practice Address - Phone:330-484-2547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.05487224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant