Provider Demographics
NPI:1063802163
Name:QUISENBERRY, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:QUISENBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CALLE AMISTAD
Mailing Address - Street 2:UNIT 5104
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-6917
Mailing Address - Country:US
Mailing Address - Phone:949-945-4788
Mailing Address - Fax:
Practice Address - Street 1:201 SANDPOINTE AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-5778
Practice Address - Country:US
Practice Address - Phone:714-557-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT10655225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant