Provider Demographics
NPI:1124632674
Name:MACK, SAMANTHA M (OTR)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:MACK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 W SWANZEY RD APT 103
Mailing Address - Street 2:
Mailing Address - City:SWANZEY
Mailing Address - State:NH
Mailing Address - Zip Code:03446-3353
Mailing Address - Country:US
Mailing Address - Phone:207-939-7931
Mailing Address - Fax:
Practice Address - Street 1:24 HILLCREST CIR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1443
Practice Address - Country:US
Practice Address - Phone:207-939-7931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3051225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist