Provider Demographics
NPI:1669883500
Name:WEAVER, SAMANTHA (OTR-L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-1500
Mailing Address - Country:US
Mailing Address - Phone:540-332-7087
Mailing Address - Fax:
Practice Address - Street 1:243 WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-1500
Practice Address - Country:US
Practice Address - Phone:540-332-7087
Practice Address - Fax:540-332-7006
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005649225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629049143Medicaid
VA1629049143Medicaid