Provider Demographics
NPI:1023756269
Name:REBHOLZ-HERTZ, SAMANTHA SUSAN (PT, DPT)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:SUSAN
Last Name:REBHOLZ-HERTZ
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 EASTPARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-2002
Mailing Address - Country:US
Mailing Address - Phone:608-440-6400
Mailing Address - Fax:
Practice Address - Street 1:4602 EASTPARK BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2002
Practice Address - Country:US
Practice Address - Phone:608-592-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15796-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist