Provider Demographics
NPI:1982956397
Name:HARGROVE, SAMANTHA JO (LMT)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:JO
Last Name:HARGROVE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9727 N WILLAMETTE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-1443
Mailing Address - Country:US
Mailing Address - Phone:917-676-5173
Mailing Address - Fax:
Practice Address - Street 1:510 NE DEKUM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-2926
Practice Address - Country:US
Practice Address - Phone:917-676-5173
Practice Address - Fax:833-563-0873
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17047225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist