=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164076204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. LEAH B. SAMLER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2019
-----------------------------------------------------
Last Update Date | 07/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 W JACKSON BLVD STE 635
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60604-3455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-482-1498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2147 N HUMBOLDT BLVD APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-1392
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-297-5561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST/COUNSELOR
-----------------------------------------------------
Name | DR. LEAH B SAMLER
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 773-297-5561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------