Healthcare Provider Details

I. General information

NPI: 1457230500
Provider Name (Legal Business Name): SAMANTHA NICOLE BALLOU OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 09/01/2025
Certification Date: 09/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 WINTON RD S
ROCHESTER NY
14623-3057
US

IV. Provider business mailing address

20 SKYCREST DR
ROCHESTER NY
14616-1410
US

V. Phone/Fax

Practice location:
  • Phone: 585-334-6000
  • Fax:
Mailing address:
  • Phone: 585-734-9737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number030522
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: