Provider Demographics
NPI:1710457478
Name:DALLAS, SAMANTHA (LCPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DALLAS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W BELMONT AVE STE 508
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3242
Mailing Address - Country:US
Mailing Address - Phone:815-474-3380
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE STE 508
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3242
Practice Address - Country:US
Practice Address - Phone:815-474-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014396101YM0800X
IL178.014261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
14371810OtherCAQH