Provider Demographics
NPI:1982178059
Name:GREENWALD, SAMANTHA (LCPC, CADC)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 W BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2108
Mailing Address - Country:US
Mailing Address - Phone:847-227-7162
Mailing Address - Fax:
Practice Address - Street 1:6033 N SHERIDAN RD STE 4
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-3003
Practice Address - Country:US
Practice Address - Phone:773-359-3505
Practice Address - Fax:312-489-8138
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL35109101YA0400X
IL180011499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty