Provider Demographics
NPI:1568943405
Name:COYLE-JOHNSON, SAMANTHA JO (MOT, OTR/L, CPST)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:COYLE-JOHNSON
Suffix:
Gender:
Credentials:MOT, OTR/L, CPST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 13TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-1570
Mailing Address - Country:US
Mailing Address - Phone:218-368-6104
Mailing Address - Fax:
Practice Address - Street 1:413 13TH AVE NE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-1570
Practice Address - Country:US
Practice Address - Phone:218-368-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1667225X00000X, 225XP0200X
HIOT-2606225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist