Healthcare Provider Details

I. General information

NPI: 1942839493
Provider Name (Legal Business Name): SAM HERDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 CLEVELAND AVE S
SAINT PAUL MN
55116-1218
US

IV. Provider business mailing address

53852 COUNTY HIGHWAY 136
HENNING MN
56551-9539
US

V. Phone/Fax

Practice location:
  • Phone: 763-913-8261
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: