Provider Demographics
NPI:1649655614
Name:BURTON, SAMANTHA (MED, LAT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BURTON
Suffix:
Gender:F
Credentials:MED, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 CALMONT AVE
Mailing Address - Street 2:#100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5012 CALMONT AVE
Practice Address - Street 2:#100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5237
Practice Address - Country:US
Practice Address - Phone:832-865-3853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT34962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer