Provider Demographics
NPI:1336859628
Name:HERNANDEZ, SAMANTHA (OTD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 BLUEBELL DR
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-5601
Mailing Address - Country:US
Mailing Address - Phone:630-487-1103
Mailing Address - Fax:
Practice Address - Street 1:11914 ILLINOIS RTE 59
Practice Address - Street 2:SUITE 134
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056015001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist