Provider Demographics
NPI:1811097397
Name:KING, SAMARA (MSOTR/L)
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10923 RUSHWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34714-7545
Mailing Address - Country:US
Mailing Address - Phone:407-314-5006
Mailing Address - Fax:352-536-9669
Practice Address - Street 1:10923 RUSHWOOD WAY
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-7545
Practice Address - Country:US
Practice Address - Phone:407-314-5006
Practice Address - Fax:352-536-9669
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL41014225800000X
FLOT11595225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8911070Medicaid
FL8911070Medicaid