Healthcare Provider Details

I. General information

NPI: 1629529995
Provider Name (Legal Business Name): SAM PSYCHIATRIC CONSULTING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 5TH ST SE SUITE #2
PINE CITY MN
55063-1580
US

IV. Provider business mailing address

253 5TH . STREET SE SUITE #2
PINE CITY MN
55063-1545
US

V. Phone/Fax

Practice location:
  • Phone: 320-629-3232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: SUSAN A MANS
Title or Position: OWNER
Credential:
Phone: 320-629-3232