Provider Demographics
NPI:1447654843
Name:LEAHY, SAMANTHA (BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LEAHY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 W GUNNISON ST APT 2D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3101
Mailing Address - Country:US
Mailing Address - Phone:815-603-5407
Mailing Address - Fax:
Practice Address - Street 1:175 E HAWTHORN PKWY STE 235
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-14-10031103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst