Basic Information
| Provider Information | |||||||||
| NPI: | 1104206846 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARNER | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| OtherLastName: | SHEMON | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 612 E OAK ST | ||||||||
| Address2: | |||||||||
| City: | GLENWOOD CITY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540138520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152654325 | ||||||||
| FaxNumber: | 7152354375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 SUBURBAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551066636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5682-26 | WI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 104386 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.