Healthcare Provider Details

I. General information

NPI: 1619497559
Provider Name (Legal Business Name): SAMANTHA WHITING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 EASTPORT CENTRE DR STE B
VALPARAISO IN
46383-4456
US

IV. Provider business mailing address

106 ARDMORE AVE
LA PORTE IN
46350-2068
US

V. Phone/Fax

Practice location:
  • Phone: 630-408-7372
  • Fax:
Mailing address:
  • Phone: 630-408-7372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33009296A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: