Provider Demographics
NPI:1366786816
Name:SERPA, SAMANTHA LEE (LMT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:SERPA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18852 SW BUTTERNUT ST APT A
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-2564
Mailing Address - Country:US
Mailing Address - Phone:503-502-5712
Mailing Address - Fax:
Practice Address - Street 1:938 SE OAK ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4214
Practice Address - Country:US
Practice Address - Phone:503-352-9167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-22
Last Update Date:2012-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19489225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist