Healthcare Provider Details

I. General information

NPI: 1275964702
Provider Name (Legal Business Name): SAMANTHA PAINTER USMILLER L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 S GRANITE ST APT A
PRESCOTT AZ
86303-4289
US

IV. Provider business mailing address

721 S GRANITE ST APT A
PRESCOTT AZ
86303-4289
US

V. Phone/Fax

Practice location:
  • Phone: 815-322-3450
  • Fax:
Mailing address:
  • Phone: 815-322-3450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-17713
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: