Provider Demographics
NPI:1952995169
Name:EGE, SAMANTHA MICHELLE (MS, LPC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:EGE
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W IRVING PARK RD STE 301
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2462
Mailing Address - Country:US
Mailing Address - Phone:872-256-2105
Mailing Address - Fax:
Practice Address - Street 1:1700 W IRVING PARK RD STE 301
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2462
Practice Address - Country:US
Practice Address - Phone:872-256-2105
Practice Address - Fax:312-327-7123
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016625101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health