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General NPI Number Information
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NPI Number | 1104416700
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Entity Type | Individual
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Provider Name | SAMANTHA BLACK MA CCC-SLP/L
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Gender | Female
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Dates
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Enumeration Date | 01/19/2021
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Last Update Date | 02/09/2023
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Provider Practice Location Address
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Address Line | 1510 E 55TH ST
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City | CHICAGO
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State | IL
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Zip | 60615-2598
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Country | US
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Telephone | 219-363-8498
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Fax |
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Provider Business Mailing Address
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Address Line | 304 N LOOMIS ST
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City | CHICAGO
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State | IL
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Zip | 60607-1147
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Country | US
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Telephone | 312-243-8487
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 146.015549
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License Number State | IL
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