Basic Information
| Provider Information | |||||||||
| NPI: | 1104557677 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KURKJIAN | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 176 WILLEY ST | ||||||||
| Address2: | |||||||||
| City: | GILBERTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601368000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302513690 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 DEAN ST | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600983220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478024058 | ||||||||
| FaxNumber: | 8153445072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2022 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071.010110 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.