Provider Demographics
NPI:1053775627
Name:WEDEMEIER, SAMANTHA LYNN (DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:WEDEMEIER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LYNN
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1932
Mailing Address - Fax:630-928-5032
Practice Address - Street 1:605 E J ST
Practice Address - Street 2:UNIT 200
Practice Address - City:FOREST CITY
Practice Address - State:IA
Practice Address - Zip Code:50436-1664
Practice Address - Country:US
Practice Address - Phone:641-585-1550
Practice Address - Fax:641-585-1551
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist