Provider Demographics
NPI:1861640393
Name:CHIARIELLO, SAMANTHA LYNN (PSYD, LCPC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:CHIARIELLO
Suffix:
Gender:F
Credentials:PSYD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16325 S. HARLEM AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1500
Mailing Address - Country:US
Mailing Address - Phone:708-689-4684
Mailing Address - Fax:
Practice Address - Street 1:16325 HARLEM AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2509
Practice Address - Country:US
Practice Address - Phone:708-689-4684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006929101YP2500X
IL071.007988103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01623882OtherBCBS