Provider Demographics
NPI:1700265592
Name:WILEY, SAMANTHA (MS, LCGC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S GREENLEAF ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3399
Mailing Address - Country:US
Mailing Address - Phone:847-336-6111
Mailing Address - Fax:
Practice Address - Street 1:202 S GREENLEAF ST
Practice Address - Street 2:SUITE E
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3399
Practice Address - Country:US
Practice Address - Phone:847-336-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL246000205170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS