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General NPI Number Information
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NPI Number | 1952895724
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Entity Type | Individual
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Provider Name | SAMANTHA MECKLENBURG CMT, HHP, HTPA, CCLS
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Gender | Female
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Dates
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Enumeration Date | 06/15/2018
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Last Update Date | 06/15/2018
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Provider Practice Location Address
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Address Line | 2801 4TH AVE
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City | SAN DIEGO
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State | CA
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Zip | 92103-6207
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Country | US
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Telephone | 619-363-1569
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Fax |
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Provider Business Mailing Address
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Address Line | 4873 NIAGARA AVE APT 9
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City | SAN DIEGO
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State | CA
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Zip | 92107-6102
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 69175
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License Number State | CA
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