Provider Demographics
NPI:1962621672
Name:SAMS, MARY SUSAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:SUSAN
Last Name:SAMS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 CHURCH ST
Mailing Address - Street 2:#212
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3875
Mailing Address - Country:US
Mailing Address - Phone:847-293-3385
Mailing Address - Fax:
Practice Address - Street 1:708 CHURCH ST
Practice Address - Street 2:#212
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3875
Practice Address - Country:US
Practice Address - Phone:847-293-3385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent