Provider Demographics
NPI:1790584027
Name:PACKARD, SAMANTHA RENE' (LMT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENE'
Last Name:PACKARD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 WINTERS RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9319
Mailing Address - Country:US
Mailing Address - Phone:989-285-0252
Mailing Address - Fax:
Practice Address - Street 1:1447 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-7739
Practice Address - Country:US
Practice Address - Phone:989-732-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011964225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist