Provider Demographics
NPI:1255152633
Name:GRAMBO, SAMANTHA (OTR/L-CLT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRAMBO
Suffix:
Gender:F
Credentials:OTR/L-CLT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:VARLJEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2024 HAMORTON PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-3530
Mailing Address - Country:US
Mailing Address - Phone:804-432-7881
Mailing Address - Fax:
Practice Address - Street 1:5820 CARMEL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8106
Practice Address - Country:US
Practice Address - Phone:704-544-4979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12806225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist