Provider Demographics
NPI:1649790577
Name:LOTTI, SAMANTHA (LAC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LOTTI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3009
Mailing Address - Country:US
Mailing Address - Phone:773-789-7143
Mailing Address - Fax:
Practice Address - Street 1:1119 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302
Practice Address - Country:US
Practice Address - Phone:773-789-7143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001246171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1225416613OtherNPI
IL453780862OtherTAX ID
1558894063OtherNPI TYPE 2#