Healthcare Provider Details

I. General information

NPI: 1336374750
Provider Name (Legal Business Name): SAMANTHA LOUISE YERKS LICSW LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA LOUISE WIEGAND LADC

II. Dates (important events)

Enumeration Date: 05/29/2009
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 HIGHWAY 61 N STE 204
WHITE BEAR LK MN
55110-2752
US

IV. Provider business mailing address

22130 TYPO CREEK DR NE
WYOMING MN
55092-4602
US

V. Phone/Fax

Practice location:
  • Phone: 763-465-6700
  • Fax: 833-590-9800
Mailing address:
  • Phone: 651-271-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number302641
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22117
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: