Provider Demographics
NPI:1447508726
Name:HOLLEKIM, SAMANTHA RAE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:HOLLEKIM
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 1:171 INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:PALERMO
Mailing Address - State:ND
Mailing Address - Zip Code:58769-9305
Mailing Address - Country:US
Mailing Address - Phone:701-629-0497
Mailing Address - Fax:
Practice Address - Street 1:1105 E FITZGERALD ST
Practice Address - Street 2:
Practice Address - City:BANGS
Practice Address - State:TX
Practice Address - Zip Code:76823-3232
Practice Address - Country:US
Practice Address - Phone:325-752-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2092222225200000X
MNA1569225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant