Basic Information
| Provider Information | |||||||||
| NPI: | 1972086288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DWYER | ||||||||
| FirstName: | SAMANTHA LYNN | ||||||||
| MiddleName: | H. NOGUEIRA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 96 DOCK WATCH HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070596926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9085078588 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 461 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CHATHAM | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079282102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736351000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01750400 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40QA01750400 | 01 | NJ | PT LICENSE NUMBER | OTHER |