Healthcare Provider Details

I. General information

NPI: 1215865795
Provider Name (Legal Business Name): SAMANTHA JANE BRODERS LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 TOLEDO AVE S
MINNEAPOLIS MN
55437-2052
US

IV. Provider business mailing address

1350 W 106TH ST
MINNEAPOLIS MN
55431-4126
US

V. Phone/Fax

Practice location:
  • Phone: 952-806-7049
  • Fax:
Mailing address:
  • Phone: 952-806-7049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number29954
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: