Healthcare Provider Details

I. General information

NPI: 1275009425
Provider Name (Legal Business Name): SAMANTHA M TOWLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MYSTIC AVE
MEDFORD MA
02155-6301
US

IV. Provider business mailing address

275 MYSTIC AVE
MEDFORD MA
02155-6301
US

V. Phone/Fax

Practice location:
  • Phone: 781-874-9294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number27274
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: