Healthcare Provider Details

I. General information

NPI: 1093218976
Provider Name (Legal Business Name): SAMANTHA BUNDY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E PLUMMER BLVD
CHATHAM IL
62629-8047
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-483-3487
  • Fax: 217-483-8150
Mailing address:
  • Phone: 217-588-2624
  • Fax: 217-757-2021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149018490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: