Provider Demographics
NPI:1972061307
Name:BLEVINS, SAMANTHA (PSYD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:BLEVINS
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 1:1091 JENNIFER LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1672
Mailing Address - Country:US
Mailing Address - Phone:618-604-1440
Mailing Address - Fax:
Practice Address - Street 1:1920 S HIGHLAND AVE STE 300
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6149
Practice Address - Country:US
Practice Address - Phone:469-476-0440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009971103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical