Provider Demographics
NPI:1265702864
Name:MULLIN, SAMANTHA J (PT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:MULLIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:WIECHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:730 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5211
Mailing Address - Country:US
Mailing Address - Phone:914-265-4595
Mailing Address - Fax:630-760-8306
Practice Address - Street 1:5255 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2450
Practice Address - Country:US
Practice Address - Phone:708-424-2977
Practice Address - Fax:708-424-2988
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018996225100000X
PAPT029109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01061943OtherMEDICARE RAILROAD
IL216859214Medicare PIN