Provider Demographics
NPI:1083403091
Name:FABISH, SAMMANTHA CRYSTA (PTA)
Entity type:Individual
Prefix:
First Name:SAMMANTHA
Middle Name:CRYSTA
Last Name:FABISH
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:SAMMANTHA
Other - Middle Name:CRYSTA
Other - Last Name:BETTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2134 E BROADWAY RD UNIT 2019
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1778
Mailing Address - Country:US
Mailing Address - Phone:618-409-1779
Mailing Address - Fax:
Practice Address - Street 1:4045 E BELL RD STE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2239
Practice Address - Country:US
Practice Address - Phone:602-992-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCP033296A225200000X
AZ014535225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant