MEDICARE: DR. SAMANTHA C COLLAZO PSY.D.

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	071010278	IL

General Provider Information

NPI Number	:	1568081172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMANTHA C COLLAZO PSY.D.

Provider Business Mailing Address
First Line	:	1516 W 18TH PL # 1R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2802
Country	:	US
Telephone Number	:	312-420-4316
Fax Number	:

Provider Business Practice Location Address
First Line	:	917 W 18TH ST STE 203
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-2400
Country	:	US
Telephone Number	:	312-620-5241
Fax Number	:

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

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	07/12/2022

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