Provider Demographics
NPI:1508696048
Name:PROCTOR, SAMANTHA MARIE (OTDR/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:OTDR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11117 HILLSBORO AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3128
Mailing Address - Country:US
Mailing Address - Phone:763-228-4274
Mailing Address - Fax:
Practice Address - Street 1:9645 GROVE CIR N STE 200
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-2684
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107536225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist