Provider Demographics
NPI:1275030199
Name:AGINS, SAMANTHA KELSEY (MA, LCPC)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:KELSEY
Last Name:AGINS
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 DES PLAINES AVE UNIT 641
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-4433
Mailing Address - Country:US
Mailing Address - Phone:224-639-7776
Mailing Address - Fax:
Practice Address - Street 1:152 ELGIN AVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130
Practice Address - Country:US
Practice Address - Phone:224-639-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013428101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health