Provider Demographics
NPI:1639483878
Name:SAMARDZIJA, SANKA (PSY D)
Entity Type:Individual
Prefix:
First Name:SANKA
Middle Name:
Last Name:SAMARDZIJA
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 EUBANK BLVD NE
Mailing Address - Street 2:STE 160
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1518
Mailing Address - Country:US
Mailing Address - Phone:505-221-6007
Mailing Address - Fax:505-738-4045
Practice Address - Street 1:2100 N MAIN ST # 304
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1877
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:574-546-1999
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008218103TC0700X
IN20043349A103TC0700X
IL071.008218103T00000X
NM1201103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist