Provider Demographics
NPI:1932698461
Name:WRZESINSKI, SAMANTHA J (RBT-18-50259)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:WRZESINSKI
Suffix:
Gender:F
Credentials:RBT-18-50259
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6520 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1834
Mailing Address - Country:US
Mailing Address - Phone:708-826-0233
Mailing Address - Fax:
Practice Address - Street 1:6520 TERRACE DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1834
Practice Address - Country:US
Practice Address - Phone:708-826-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18-50259106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician