Provider Demographics
NPI:1770275901
Name:GRASSO, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRASSO
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 1:14 RED TAIL CT
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-5658
Mailing Address - Country:US
Mailing Address - Phone:203-767-4491
Mailing Address - Fax:
Practice Address - Street 1:19 OLD KINGS HWY S
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4533
Practice Address - Country:US
Practice Address - Phone:203-621-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist