Provider Demographics
NPI:1912768235
Name:MCAVOY, SAMANTHA J (MS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:MCAVOY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HENRY
Mailing Address - State:IL
Mailing Address - Zip Code:61537-1619
Mailing Address - Country:US
Mailing Address - Phone:309-648-4431
Mailing Address - Fax:
Practice Address - Street 1:1011 FRONT ST
Practice Address - Street 2:
Practice Address - City:HENRY
Practice Address - State:IL
Practice Address - Zip Code:61537-1619
Practice Address - Country:US
Practice Address - Phone:309-648-4431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician