Provider Demographics
NPI:1104416700
Name:BLACK, SAMANTHA (MA CCC-SLP/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1147
Mailing Address - Country:US
Mailing Address - Phone:312-243-8487
Mailing Address - Fax:
Practice Address - Street 1:1510 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-2598
Practice Address - Country:US
Practice Address - Phone:219-363-8498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.015549235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619340874Medicaid