Provider Demographics
NPI:1740631761
Name:MCCLEAN, SAMANTHA (LMT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MCCLEAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1261 S SEWARD MERIDIAN PKWY
Mailing Address - Street 2:SUITE F
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8372
Mailing Address - Country:US
Mailing Address - Phone:907-357-6100
Mailing Address - Fax:907-357-6102
Practice Address - Street 1:1261 S SEWARD MERIDIAN PKWY
Practice Address - Street 2:SUITE F
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8372
Practice Address - Country:US
Practice Address - Phone:907-357-6100
Practice Address - Fax:907-357-6102
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101857225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist