Provider Demographics
NPI:1366923682
Name:SORCE, SAMANTHA (DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SORCE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 AGATE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1178
Mailing Address - Country:US
Mailing Address - Phone:858-217-2496
Mailing Address - Fax:
Practice Address - Street 1:11848 BERNARDO PLAZA CT STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2417
Practice Address - Country:US
Practice Address - Phone:951-595-1757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT293482OtherLICENSE