Provider Demographics
NPI:1275940538
Name:SCHMERBAUCH, SAMANTHA LANE
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:LANE
Last Name:SCHMERBAUCH
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 1:8115 SHAWNEETOWN TRL
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:62233-2705
Mailing Address - Country:US
Mailing Address - Phone:618-615-3364
Mailing Address - Fax:
Practice Address - Street 1:8115 SHAWNEETOWN TRL
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:IL
Practice Address - Zip Code:62233-2705
Practice Address - Country:US
Practice Address - Phone:618-615-3364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILS561-7929-0908222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist