Healthcare Provider Details

I. General information

NPI: 1619521176
Provider Name (Legal Business Name): SAMANTHA SERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4908 N ELSTON AVE
CHICAGO IL
60630-2506
US

IV. Provider business mailing address

4908 N ELSTON AVE
CHICAGO IL
60630-2506
US

V. Phone/Fax

Practice location:
  • Phone: 773-205-8505
  • Fax:
Mailing address:
  • Phone: 773-205-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number152.000423
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: