Provider Demographics
NPI:1548931231
Name:MAXWELL-WHAM, SAMARA KAY (PTA)
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:KAY
Last Name:MAXWELL-WHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SAMARA
Other - Middle Name:KAY
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA, LMT
Mailing Address - Street 1:11914 ASTORIA BLVD STE 620
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6051
Mailing Address - Country:US
Mailing Address - Phone:281-929-4475
Mailing Address - Fax:
Practice Address - Street 1:11914 ASTORIA BLVD STE 620
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6051
Practice Address - Country:US
Practice Address - Phone:281-929-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-1473-4225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant