Provider Demographics
NPI:1699910570
Name:MAIDEN, SAMANTHA (PT, MSED)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MAIDEN
Suffix:
Gender:F
Credentials:PT, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:FRAKES
Mailing Address - State:KY
Mailing Address - Zip Code:40940-0337
Mailing Address - Country:US
Mailing Address - Phone:606-347-2398
Mailing Address - Fax:606-337-8232
Practice Address - Street 1:133 HENDERSON CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-9134
Practice Address - Country:US
Practice Address - Phone:606-347-2398
Practice Address - Fax:606-337-8232
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT00001776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5020201Medicare UPIN