Provider Demographics
NPI:1609233139
Name:HENNELLY, SAMANTHA (MS, CF-SLP)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:HENNELLY
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 N NEWLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-3757
Mailing Address - Country:US
Mailing Address - Phone:773-369-0055
Mailing Address - Fax:
Practice Address - Street 1:3350 N NEWLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-3757
Practice Address - Country:US
Practice Address - Phone:773-369-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.003623235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist