Provider Demographics
NPI:1669965042
Name:SPELLMAN, SAMANTHA LEANN (MSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEANN
Last Name:SPELLMAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E CENTRAL AVE BLDG 420
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-1050
Mailing Address - Country:US
Mailing Address - Phone:217-877-9117
Mailing Address - Fax:
Practice Address - Street 1:701 DEVONSHIRE DR STE B16-18
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7337
Practice Address - Country:US
Practice Address - Phone:217-531-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1821055658Medicaid