Healthcare Provider Details

I. General information

NPI: 1134932957
Provider Name (Legal Business Name): SAMUEL DYLAN GOBEL LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 8TH ST SE
DETROIT LAKES MN
56501-2839
US

IV. Provider business mailing address

26510 COUNTY ROAD 149
DETROIT LAKES MN
56501-7681
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-1676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04776
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: