Provider Demographics
NPI:1538535844
Name:DOMKE, SAMANTHA (PT DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DOMKE
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 1:1223 WOODNOLL DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-4715
Mailing Address - Country:US
Mailing Address - Phone:810-449-4234
Mailing Address - Fax:
Practice Address - Street 1:2138 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-8482
Practice Address - Country:US
Practice Address - Phone:810-449-4234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004695225200000X
MI5501302864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant