Provider Demographics
NPI:1811257348
Name:HERRIOTT, SAMANTHA (PT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HERRIOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-1323
Mailing Address - Fax:
Practice Address - Street 1:3101 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3743
Practice Address - Country:US
Practice Address - Phone:217-366-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist