Healthcare Provider Details

I. General information

NPI: 1003279464
Provider Name (Legal Business Name): MONICA KRISTIN SAMELSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2016
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 W CUYLER AVE STE 103
CHICAGO IL
60613-2541
US

IV. Provider business mailing address

1806 W CUYLER AVE STE 103
CHICAGO IL
60613-2541
US

V. Phone/Fax

Practice location:
  • Phone: 206-558-5495
  • Fax:
Mailing address:
  • Phone: 206-558-5495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD60978381
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number183790
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036.163441
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: