MEDICARE: SAM CLUBB 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
1	1041C0700X	Clinical Social Worker	68633	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174230130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAM CLUBB LCSW

Provider Business Mailing Address
First Line	:	1023 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2913
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1023 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2913
Country	:	US
Telephone Number	:	832-623-9257
Fax Number	:

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

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	02/15/2023

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Directions to “ SAM CLUBB LCSW” Practice Location

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