Provider Demographics
NPI:1750093761
Name:BURCH, SAMANTHA JO (LMT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:BURCH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:SCHIPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:940 HANSEN RD STE F
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5377
Mailing Address - Country:US
Mailing Address - Phone:920-496-6000
Mailing Address - Fax:920-496-0998
Practice Address - Street 1:940 HANSEN RD STE F
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5377
Practice Address - Country:US
Practice Address - Phone:920-496-6000
Practice Address - Fax:920-496-0998
Is Sole Proprietor?:No
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15477-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist