Provider Demographics
NPI:1265870422
Name:POWELL, SAMANTHA RAE (LAT, ATC, PES)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:POWELL
Suffix:
Gender:F
Credentials:LAT, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 HOLLYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15205-3432
Mailing Address - Country:US
Mailing Address - Phone:330-573-1404
Mailing Address - Fax:
Practice Address - Street 1:107 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-2871
Practice Address - Country:US
Practice Address - Phone:412-365-1470
Practice Address - Fax:412-365-1724
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0039242255A2300X
PART0055072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer