Provider Demographics
NPI:1962990044
Name:SHAPIRO, SAMANTHA TESS
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TESS
Last Name:SHAPIRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W ARLINGTON PL APT 509
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5993
Mailing Address - Country:US
Mailing Address - Phone:847-845-6448
Mailing Address - Fax:
Practice Address - Street 1:3919 W FOSTER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-6056
Practice Address - Country:US
Practice Address - Phone:773-588-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013849235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist