Healthcare Provider Details

I. General information

NPI: 1477887974
Provider Name (Legal Business Name): SAMANTHA SOTHERDEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 OLD LIVERPOOL RD
LIVERPOOL NY
13088-6332
US

IV. Provider business mailing address

2222 SULLIVAN TRL
EASTON PA
18040-7958
US

V. Phone/Fax

Practice location:
  • Phone: 516-492-5708
  • Fax: 631-467-0928
Mailing address:
  • Phone: 516-492-5708
  • Fax: 631-467-0928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number043416
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number006766-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: