Provider Demographics
NPI:1467197954
Name:PEACHEY, SAMANTHA ADAMS
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ADAMS
Last Name:PEACHEY
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 1:935 W AGATITE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2706
Mailing Address - Country:US
Mailing Address - Phone:216-970-7488
Mailing Address - Fax:
Practice Address - Street 1:1757 N KIMBALL AVE STE 202
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4805
Practice Address - Country:US
Practice Address - Phone:312-463-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.000946106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208.000946OtherASSOCIATE LICENSED MARRIAGE AND FAMILY THERAPIST