Healthcare Provider Details

I. General information

NPI: 1124213939
Provider Name (Legal Business Name): NANCY L SAMUELSON OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 4TH ST SE
LAKE PRESTON SD
57249-2116
US

IV. Provider business mailing address

1800 OHIO DR
BROOKINGS SD
57006-2353
US

V. Phone/Fax

Practice location:
  • Phone: 605-847-4405
  • Fax:
Mailing address:
  • Phone: 605-692-7589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0042
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: