Provider Demographics
NPI:1740322502
Name:SAMUELSON, MARK STEVEN (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 CRAWFORD AVENUE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4983
Mailing Address - Country:US
Mailing Address - Phone:847-475-9500
Mailing Address - Fax:312-782-8276
Practice Address - Street 1:2550 CRAWFORD AVENUE
Practice Address - Street 2:SUITE 14
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4983
Practice Address - Country:US
Practice Address - Phone:847-475-9500
Practice Address - Fax:312-782-8276
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490009361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-71240OtherBLUE CROSS OF ILLINOIS
IL348588200OtherDEPT. OF LABOR OWCP
IL342170Medicare ID - Type UnspecifiedMEDICARE PART B