Provider Demographics
NPI:1457727554
Name:KOLIBAS, SAMANTHA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KOLIBAS
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 CLIFTON AVE
Mailing Address - Street 2:# 345
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1453
Mailing Address - Country:US
Mailing Address - Phone:973-928-3590
Mailing Address - Fax:
Practice Address - Street 1:49 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4854
Practice Address - Country:US
Practice Address - Phone:973-680-8390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002069002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer