Provider Demographics
NPI:1962877241
Name:OLSEN, SAMANTHA (DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:OLSEN
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 1:4 RICHMOND SQ STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5117
Mailing Address - Country:US
Mailing Address - Phone:401-433-4172
Mailing Address - Fax:401-433-0612
Practice Address - Street 1:91 MAIN ST STE 122
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-4437
Practice Address - Country:US
Practice Address - Phone:401-289-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22095225100000X
RIPT03228225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist