Provider Demographics
NPI:1487124376
Name:SMITH, SAMUEL (OTR/L)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 S FREEPORT RD STE 1A
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6160
Mailing Address - Country:US
Mailing Address - Phone:207-865-5520
Mailing Address - Fax:
Practice Address - Street 1:174 S FREEPORT RD STE 1A
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6160
Practice Address - Country:US
Practice Address - Phone:207-865-5520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2831225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation