Provider Demographics
NPI:1700558533
Name:ROSA, SAMANTHA A (MT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:A
Last Name:ROSA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 21ST AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1483
Mailing Address - Country:US
Mailing Address - Phone:303-678-7170
Mailing Address - Fax:
Practice Address - Street 1:451 21ST AVE STE A
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1483
Practice Address - Country:US
Practice Address - Phone:303-678-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225700000X
CO171435017225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist