Provider Demographics
NPI:1841662236
Name:SAM, VICTORIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 SHAKERAG HL STE C
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-6524
Mailing Address - Country:US
Mailing Address - Phone:770-487-0760
Mailing Address - Fax:770-487-0815
Practice Address - Street 1:3200 SHAKERAG HL STE C
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-6524
Practice Address - Country:US
Practice Address - Phone:770-487-0760
Practice Address - Fax:770-487-0815
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211591225100000X
GAPT013480225100000X
DCPT871875225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist