Basic Information
| Provider Information | |||||||||
| NPI: | 1073083655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAMPEMANE | ||||||||
| FirstName: | MAMTA | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | P. O. BOX 500 | ||||||||
| Address2: | |||||||||
| City: | BROOKEVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208330500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014988100 | ||||||||
| FaxNumber: | 3014980009 | ||||||||
| Practice Location | |||||||||
| Address1: | 14409 GREENVIEW DRIVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014988100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2018 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 05234 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 05234 | 01 | MD | MARYLAND DEPT OF HEALTH & MENTAL HYGIENE | OTHER |