Provider Demographics
NPI:1720451412
Name:SMITH, SAMANTHA (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, ATC
Mailing Address - Street 1:163 NORTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6192
Mailing Address - Country:US
Mailing Address - Phone:207-505-4584
Mailing Address - Fax:
Practice Address - Street 1:163 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6192
Practice Address - Country:US
Practice Address - Phone:207-505-4584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT4762255A2300X
MEPT3960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer