Basic Information
| Provider Information | |||||||||
| NPI: | 1801525977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMANO | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, LSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SAMANO | ||||||||
| OtherFirstName: | DIANA | ||||||||
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| OtherCredential: | MSW, LSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2530 RIDGE AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602012493 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 950 LEE ST | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600166532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474864140 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 150107593 | IL | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.