Provider Demographics
NPI:1811380835
Name:STACK, SAMANTHA (LCPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:STACK
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 1:3301 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2715
Mailing Address - Country:US
Mailing Address - Phone:708-995-3726
Mailing Address - Fax:
Practice Address - Street 1:3301 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2715
Practice Address - Country:US
Practice Address - Phone:312-469-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-16
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor