Provider Demographics
NPI:1972312858
Name:GLEASON, SAMANTHA (PT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GLEASON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:13203 GLOBE DR STE 111
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-1616
Mailing Address - Country:US
Mailing Address - Phone:262-287-0090
Mailing Address - Fax:262-923-1939
Practice Address - Street 1:3615 WASHINGTON RD STE A
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1640
Practice Address - Country:US
Practice Address - Phone:262-287-0090
Practice Address - Fax:262-923-1939
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17024-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist