Provider Demographics
NPI:1386236487
Name:WHITESIDE, SAMANTHA (DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WHITESIDE
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 1:19557 CRYSTAL RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19510 VENTURA BLVD STE 106
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2974
Practice Address - Country:US
Practice Address - Phone:818-996-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist