Provider Demographics
NPI:1649492539
Name:WELTER, SAMANTHA L (ATC)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:L
Last Name:WELTER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TRADERS CIRCLE
Mailing Address - Street 2:257
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 HORTON FIELDHOUSE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-7130
Practice Address - Country:US
Practice Address - Phone:309-438-3340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer