Provider Demographics
NPI:1528875622
Name:BROWN, SAMANTHA TANNER (DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TANNER
Last Name:BROWN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:SHAWN
Other - Last Name:CLEMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:2556 TOBACCO RD STE C
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-9016
Practice Address - Country:US
Practice Address - Phone:706-309-0036
Practice Address - Fax:706-842-3017
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist