Provider Demographics
NPI:1538600184
Name:PETERS, SAMANTHA RENEE (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:PETERS
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5834 WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-2743
Mailing Address - Country:US
Mailing Address - Phone:330-550-8493
Mailing Address - Fax:
Practice Address - Street 1:78078 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-8173
Practice Address - Country:US
Practice Address - Phone:760-345-9934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA292690225100000X
NM4945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist