Provider Demographics
NPI:1790207868
Name:VAZQUEZ, SAMANTHA MARIE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MARIE
Other - Last Name:MCGLUMPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:10104 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3527
Mailing Address - Country:US
Mailing Address - Phone:304-280-6360
Mailing Address - Fax:
Practice Address - Street 1:10104 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3527
Practice Address - Country:US
Practice Address - Phone:304-280-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health