Provider Demographics
NPI:1801295076
Name:MASSIE, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MASSIE
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 1:1117 S BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MO
Mailing Address - Zip Code:65281-1237
Mailing Address - Country:US
Mailing Address - Phone:660-414-7305
Mailing Address - Fax:
Practice Address - Street 1:1117 S BAKER AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MO
Practice Address - Zip Code:65281-1237
Practice Address - Country:US
Practice Address - Phone:660-414-7305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013033222225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist