Provider Demographics
NPI:1801516224
Name:SANDERS, SAMANTHA JO (OTR/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:SANDERS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MAPLE ST #467
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:MA
Mailing Address - Zip Code:01516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28 MAPLE ST #467
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MA
Practice Address - Zip Code:01516
Practice Address - Country:US
Practice Address - Phone:214-418-7902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0004858225X00000X
IDOT-2408225X00000X
MA14527225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist