MEDICARE: MS. SAMANTHA ANNE MIEMCZEWSKI LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	180012163	IL

General Provider Information

NPI Number	:	1033456348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SAMANTHA ANNE MIEMCZEWSKI LCPC

Provider Business Mailing Address
First Line	:	3805 E MAIN ST STE M
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60174-2487
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3805 E MAIN ST STE M
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60174-2487
Country	:	US
Telephone Number	:	630-305-5118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2013
Last Update Date	:	02/27/2024

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