Healthcare Provider Details

I. General information

NPI: 1801295076
Provider Name (Legal Business Name): SAMANTHA MASSIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 S BAKER AVE
SALISBURY MO
65281-1237
US

IV. Provider business mailing address

1117 S BAKER AVE
SALISBURY MO
65281-1237
US

V. Phone/Fax

Practice location:
  • Phone: 660-414-7305
  • Fax:
Mailing address:
  • Phone: 660-414-7305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2013033222
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: