Provider Demographics
NPI:1679928253
Name:SAMANTHA ZYLSTRA
Entity Type:Organization
Organization Name:SAMANTHA ZYLSTRA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZYLSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:415-585-3132
Mailing Address - Street 1:50 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-5484
Mailing Address - Country:US
Mailing Address - Phone:415-585-3132
Mailing Address - Fax:
Practice Address - Street 1:50 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5484
Practice Address - Country:US
Practice Address - Phone:415-585-3132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000962106H00000X
CA44677106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty