Provider Demographics
NPI:1124500129
Name:METZ, SAMANTHA ALYCE (LMT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ALYCE
Last Name:METZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 COUNTY ROAD J
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-1051
Mailing Address - Country:US
Mailing Address - Phone:608-577-2667
Mailing Address - Fax:
Practice Address - Street 1:6417 ODANA RD STE 25
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1159
Practice Address - Country:US
Practice Address - Phone:608-577-2667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12983-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty