Provider Demographics
NPI:1184232183
Name:SAMUELSON, ISAAC WILLIAM (LPC)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:WILLIAM
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3058 W CORTLAND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5075
Mailing Address - Country:US
Mailing Address - Phone:404-661-0945
Mailing Address - Fax:
Practice Address - Street 1:3058 W CORTLAND ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5075
Practice Address - Country:US
Practice Address - Phone:404-661-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.015973101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor