Healthcare Provider Details

I. General information

NPI: 1699530568
Provider Name (Legal Business Name): SAMANTHA ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 ANDERSON HEALTHCARE DR
EDWARDSVILLE IL
62025-7712
US

IV. Provider business mailing address

655 S WILLOW ST STE 128
MANCHESTER NH
03103-5723
US

V. Phone/Fax

Practice location:
  • Phone: 618-307-7900
  • Fax:
Mailing address:
  • Phone: 800-995-2673
  • Fax: 866-420-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056015048
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: