MEDICARE: SAMANTHA MARCINETTE EVANS MS, LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	CC02579	MN

General Provider Information

NPI Number	:	1326654617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA MARCINETTE EVANS MS, LPCC

Provider Business Mailing Address
First Line	:	303 SE 1ST ST
Second Line	:
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3681
Country	:	US
Telephone Number	:	218-380-7310
Fax Number	:	218-999-7068

Provider Business Practice Location Address
First Line	:	4225 TECHNOLOGY DR NW
Second Line	:
City	:	BEMIDJI
State	:	MN
Zip	:	56601-5118
Country	:	US
Telephone Number	:	218-751-0281
Fax Number	:	218-751-0870

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2020
Last Update Date	:	09/22/2020

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