Provider Demographics
NPI:1013559772
Name:WALSH, SAMANTHA CHRISTINE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CHRISTINE
Last Name:WALSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 PENNSYLVANIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4427
Mailing Address - Country:US
Mailing Address - Phone:630-474-4353
Mailing Address - Fax:
Practice Address - Street 1:420 PENNSYLVANIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4427
Practice Address - Country:US
Practice Address - Phone:630-474-4353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178015101OtherIDFPR LISENCE NUMBER