Provider Demographics
NPI:1780236349
Name:FORDHAM, SAMANTHA NICOLE (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:FORDHAM
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:NICOLE
Other - Last Name:LOCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:89 LITTMAN RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32352-8825
Mailing Address - Country:US
Mailing Address - Phone:813-401-7756
Mailing Address - Fax:
Practice Address - Street 1:3101 GINGER DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4477
Practice Address - Country:US
Practice Address - Phone:850-877-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16155225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist