Healthcare Provider Details

I. General information

NPI: 1104601335
Provider Name (Legal Business Name): SAMANTHA LEE WOLLER LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 6TH AVE S # 100
SAINT CLOUD MN
56301-5209
US

IV. Provider business mailing address

116 COLE CT
MANKATO MN
56001-6426
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-5930
  • Fax:
Mailing address:
  • Phone: 507-779-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4387
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: