Provider Demographics
NPI:1669716817
Name:RICKMON, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RICKMON
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 1:1748 PERIWINKLE DR
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-5400
Mailing Address - Country:US
Mailing Address - Phone:815-545-2069
Mailing Address - Fax:
Practice Address - Street 1:1748 PERIWINKLE DR
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-5400
Practice Address - Country:US
Practice Address - Phone:815-545-2069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-11
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist