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NPI Code Detail

MEDICARE: SAMANTHA STACK LCPC

MEDICARE: SAMANTHA STACK 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
1101Y00000XCounselor
2101YM0800XMental Health CounselorIL

General Provider Information

NPI Number : 1811380835
Entity Type Code : Individual
Provider Name (Legal Business Name) : SAMANTHA STACK LCPC
Provider Business Mailing Address
First Line : 3301 W 111TH ST
Second Line :
City : CHICAGO
State : IL
Zip : 60655-2715
Country : US
Telephone Number : 708-995-3726
Fax Number :
Provider Business Practice Location Address
First Line : 3301 W 111TH ST
Second Line :
City : CHICAGO
State : IL
Zip : 60655-2715
Country : US
Telephone Number : 312-469-0486
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/16/2015
Last Update Date : 12/01/2020

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