=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619338498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA EVERETTE OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2016
-----------------------------------------------------
Last Update Date | 04/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8840 N MAGNOLIA AVE STE 220
-----------------------------------------------------
City | SANTEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92071-4516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-692-0622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1744 KENWELL ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92139-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 10204
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 18590
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------