Provider Demographics
NPI:1972791556
Name:SAMPSON, CARLY BRIANN (LMT)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:BRIANN
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:BRIANN
Other - Last Name:PUNZALAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1102 W HAYDEN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835
Mailing Address - Country:US
Mailing Address - Phone:208-620-7150
Mailing Address - Fax:208-620-7120
Practice Address - Street 1:1102 W HAYDEN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835
Practice Address - Country:US
Practice Address - Phone:208-620-7150
Practice Address - Fax:208-620-7120
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024004225700000X
IDMAS4614225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0222574OtherWA DEPT.LABOR&INDUSTRIES