Healthcare Provider Details

I. General information

NPI: 1023702875
Provider Name (Legal Business Name): SAMANTHA RENEE DELORENZO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GALISTEO ST
SANTA FE NM
87505-4747
US

IV. Provider business mailing address

8802 SUMMER SERENADE DR
HUNTERSVILLE NC
28078-2362
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-8313
  • Fax:
Mailing address:
  • Phone: 973-945-6968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPT-2024-0037
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: