Provider Demographics
NPI:1275728370
Name:LUSSIER, SAMANTHA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:M
Last Name:LUSSIER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W 35TH ST
Mailing Address - Street 2:5B5220
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-1305
Mailing Address - Country:US
Mailing Address - Phone:312-548-9051
Mailing Address - Fax:
Practice Address - Street 1:1200 W 35TH ST
Practice Address - Street 2:5B5220
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-1305
Practice Address - Country:US
Practice Address - Phone:312-548-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008957103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical