Basic Information
| Provider Information | |||||||||
| NPI: | 1093218976 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNDY | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175882624 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E PLUMMER BLVD | ||||||||
| Address2: | |||||||||
| City: | CHATHAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626298047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174833487 | ||||||||
| FaxNumber: | 2174838150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2018 | ||||||||
| LastUpdateDate: | 03/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149018490 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 149018490 | 01 | IL | LCSW LICENSE | OTHER |