Provider Demographics
NPI:1669755047
Name:TEMPLE, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TEMPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91A HARBOR ST
Mailing Address - Street 2:
Mailing Address - City:PEPPERELL
Mailing Address - State:MA
Mailing Address - Zip Code:01463-1261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 SHORE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3154
Practice Address - Country:US
Practice Address - Phone:508-853-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist