MEDICARE: SAMANTHA MIZOCK 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	103TR0400X	Rehabilitation Psychologist	596721	IL
2	101YM0800X	Mental Health Counselor	180.016678	IL

General Provider Information

NPI Number	:	1255051892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA MIZOCK LCPC

Provider Business Mailing Address
First Line	:	1550 N NORTHWEST HWY STE 360
Second Line	:
City	:	PARK RIDGE
State	:	IL
Zip	:	60068-1461
Country	:	US
Telephone Number	:	847-299-3400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 N NORTHWEST HWY STE 360
Second Line	:
City	:	PARK RIDGE
State	:	IL
Zip	:	60068-1461
Country	:	US
Telephone Number	:	847-299-3400
Fax Number	:

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

Provider Enumeration Date	:	09/01/2022
Last Update Date	:	01/29/2025

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Directions to “ SAMANTHA MIZOCK LCPC” Practice Location

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