MEDICARE: SAMANTHA LAWRENCE DT

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	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1629274741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LAWRENCE DT

Provider Business Mailing Address
First Line	:	180 N JEFFERSON ST UNIT 2010
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60661-1457
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3712 N BROADWAY ST
Second Line	:	STE 250
City	:	CHICAGO
State	:	IL
Zip	:	60613-4235
Country	:	US
Telephone Number	:	773-615-3202
Fax Number	:

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

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/08/2007

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