=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639483878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANKA SAMARDZIJA PSY D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2010
-----------------------------------------------------
Last Update Date | 02/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 N MAIN ST # 304
-----------------------------------------------------
City | CROWN POINT
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46307-1877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-546-1900
-----------------------------------------------------
Fax | 574-546-1999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5600 EUBANK BLVD NE STE 160
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-1518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-221-6007
-----------------------------------------------------
Fax | 505-738-4045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071008218
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 20043349A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 071.008218
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 1201
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------