Healthcare Provider Details

I. General information

NPI: 1083278543
Provider Name (Legal Business Name): SAMANTHA NICOLE ROGOZYNSKI OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date: 07/27/2022
Reactivation Date: 08/18/2022

III. Provider practice location address

212 MAIN ST
STEVENSVILLE MT
59870-2111
US

IV. Provider business mailing address

212 MAIN ST
STEVENSVILLE MT
59870-2111
US

V. Phone/Fax

Practice location:
  • Phone: 406-201-9213
  • Fax: 406-215-9002
Mailing address:
  • Phone: 406-201-9213
  • Fax: 406-215-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTP-OT-LIC-9458
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: