Provider Demographics
NPI:1306682208
Name:WALLENBERG, SAMANTHA LAUREN (MS, OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LAUREN
Last Name:WALLENBERG
Suffix:
Gender:F
Credentials:MS, OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2536 W CORTEZ ST APT BF
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-3456
Mailing Address - Country:US
Mailing Address - Phone:224-595-8744
Mailing Address - Fax:
Practice Address - Street 1:310 MOSHER DR
Practice Address - Street 2:
Practice Address - City:PROPHETSTOWN
Practice Address - State:IL
Practice Address - Zip Code:61277-1001
Practice Address - Country:US
Practice Address - Phone:309-525-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.013694225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist