=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235006909
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA WILSON LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2025
-----------------------------------------------------
Last Update Date | 10/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 704 E WAYNE ST
-----------------------------------------------------
City | CELINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45822-1380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-644-1538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 W MARKET ST
-----------------------------------------------------
City | CELINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45822-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-644-1538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 33.027474
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------