Provider Demographics
NPI:1053710509
Name:FENNO, SAMANTHA MAE (LCSW)
Entity type:Individual
Prefix:PROF
First Name:SAMANTHA
Middle Name:MAE
Last Name:FENNO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E WASHINGTON ST STE 1717
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1839
Mailing Address - Country:US
Mailing Address - Phone:410-493-6028
Mailing Address - Fax:
Practice Address - Street 1:25 E WASHINGTON ST STE 1717
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1839
Practice Address - Country:US
Practice Address - Phone:410-493-6028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490168201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical