Provider Demographics
NPI:1477351757
Name:TADLOCK, SAMANTHA LEIGH (PTA)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:LEIGH
Last Name:TADLOCK
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 RONALD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2637
Mailing Address - Country:US
Mailing Address - Phone:704-995-0407
Mailing Address - Fax:
Practice Address - Street 1:100 ALLAWOOD CT STE 110
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-6207
Practice Address - Country:US
Practice Address - Phone:864-525-2654
Practice Address - Fax:864-757-8811
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant