Provider Demographics
NPI:1720760143
Name:HARLAN, SAMANTHA (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HARLAN
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 FRANK SCOTT PKWY W STE 930
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-5010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 FRANK SCOTT PKWY W STE 930
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-5010
Practice Address - Country:US
Practice Address - Phone:618-234-9705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-04
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA121648225X00000X
IL056016612225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist