Provider Demographics
NPI:1972071645
Name:WALSH, SAMANTHA MARIE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13377 NW COUNTY ROAD 2001
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MO
Mailing Address - Zip Code:64720-5099
Mailing Address - Country:US
Mailing Address - Phone:816-507-0276
Mailing Address - Fax:
Practice Address - Street 1:3001 E ELM ST
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-1196
Practice Address - Country:US
Practice Address - Phone:816-380-6525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-11
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018027220225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant