MEDICARE: ALICIA RENEE SAMP

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	103TC0700X	Clinical Psychologist	07102246	IL

General Provider Information

NPI Number	:	1528674231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA RENEE SAMP

Provider Business Mailing Address
First Line	:	160 E GRAND AVE STE 5
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3800
Country	:	US
Telephone Number	:	847-686-0090
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 E GRAND AVE STE 5
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3800
Country	:	US
Telephone Number	:	847-686-0090
Fax Number	:

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

Provider Enumeration Date	:	09/17/2020
Last Update Date	:	10/13/2025

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Directions to “ ALICIA RENEE SAMP ” Practice Location

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