Provider Demographics
NPI:1679040141
Name:SCHMELTER, SAMANTHA MARIE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:SCHMELTER
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 1:108 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3918
Mailing Address - Country:US
Mailing Address - Phone:309-827-5351
Mailing Address - Fax:
Practice Address - Street 1:1102 JOG RD
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1275
Practice Address - Country:US
Practice Address - Phone:475-133-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178011951101YP2500X
IL180011953101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional