=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629948997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRA REGINA SAMUELS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2025
-----------------------------------------------------
Last Update Date | 11/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2720 SUNSET BLVD
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-4810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-791-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 624 GIBSON RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29072-2432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-422-2058
-----------------------------------------------------
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 | 7810
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------