Healthcare Provider Details

I. General information

NPI: 1013559772
Provider Name (Legal Business Name): SAMANTHA CHRISTINE WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 PENNSYLVANIA AVE STE 101
GLEN ELLYN IL
60137-4427
US

IV. Provider business mailing address

420 PENNSYLVANIA AVE STE 101
GLEN ELLYN IL
60137-4427
US

V. Phone/Fax

Practice location:
  • Phone: 630-474-4353
  • Fax:
Mailing address:
  • Phone: 630-474-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: