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NPI Code Detail

MEDICARE: PROF. SAMANTHA MAE FENNO LCSW

MEDICARE: PROF. SAMANTHA MAE FENNO LCSW
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
11041C0700XClinical Social Worker149016820IL

General Provider Information

NPI Number : 1053710509
Entity Type Code : Individual
Provider Name (Legal Business Name) : PROF. SAMANTHA MAE FENNO LCSW
Provider Business Mailing Address
First Line : 25 E WASHINGTON ST STE 1717
Second Line :
City : CHICAGO
State : IL
Zip : 60602-1839
Country : US
Telephone Number : 410-493-6028
Fax Number :
Provider Business Practice Location Address
First Line : 25 E WASHINGTON ST STE 1717
Second Line :
City : CHICAGO
State : IL
Zip : 60602-1839
Country : US
Telephone Number : 410-493-6028
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/21/2014
Last Update Date : 09/02/2019

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