Provider Demographics
NPI:1740771377
Name:STUFFLEBAM, SAMANTHA JO (LSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:STUFFLEBAM
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:MRS
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:STUFFLEBAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SAMANTHA BREMER, MSW
Mailing Address - Street 1:5000 S 5TH AVE BLDG 228
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:IL
Mailing Address - Zip Code:60141-3030
Mailing Address - Country:US
Mailing Address - Phone:708-202-8387
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE BLDG 228
Practice Address - Street 2:
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150102016104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker