Provider Demographics
NPI:1194232314
Name:FLYNN, SAMANTHA JO
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JO
Last Name:FLYNN
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 1:16100 N 1800TH ST
Mailing Address - Street 2:
Mailing Address - City:TEUTOPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62467-3212
Mailing Address - Country:US
Mailing Address - Phone:217-663-3542
Mailing Address - Fax:
Practice Address - Street 1:802 N GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-3200
Practice Address - Country:US
Practice Address - Phone:217-343-3089
Practice Address - Fax:217-690-4846
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.011365225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1578775730OtherBARB UTZ