Provider Demographics
NPI:1891132080
Name:KISILEWICZ, SAMANTHA (ATC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KISILEWICZ
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LEONHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:754 NOTRE DAME AVENUE
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-1219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:754 NOTRE DAME AVE
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1219
Practice Address - Country:US
Practice Address - Phone:330-592-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT. 0040452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer