Provider Demographics
NPI:1013326719
Name:ROSE, SAMANTHA BROOKE (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:BROOKE
Last Name:ROSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:BROOKE
Other - Last Name:PAYTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:2948 ARTESIAN RD STE 112
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8559
Mailing Address - Country:US
Mailing Address - Phone:630-428-7890
Mailing Address - Fax:
Practice Address - Street 1:2948 ARTESIAN RD STE 112
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8559
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.102587104100000X
MO2014023629104100000X
IL1490224391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker