Provider Demographics
NPI:1306529995
Name:STACK, SAMANTHA (PT, DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CLIFTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:3959 RUFFIN RD STE J
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1830
Mailing Address - Country:US
Mailing Address - Phone:858-279-5570
Mailing Address - Fax:858-279-5303
Practice Address - Street 1:3145 ROSECRANS ST STE F
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4831
Practice Address - Country:US
Practice Address - Phone:619-223-7175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist