Provider Demographics
NPI:1285076901
Name:MCCRACKEN, SAMANTHA JO (PT, DPT, ATC)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JO
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:8726 US 42
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-9625
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-817-7848
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.014263225100000X
KY006241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100259410Medicaid
KY7100259410Medicaid