Provider Demographics
NPI:1205300308
Name:SAMUELS, KATIE NICOLE (PT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:NICOLE
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4725 S 1300 E APT 21
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5099
Mailing Address - Country:US
Mailing Address - Phone:801-413-8868
Mailing Address - Fax:
Practice Address - Street 1:1685 W 2200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1456
Practice Address - Country:US
Practice Address - Phone:801-478-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-30440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist