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General NPI Number Information
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NPI Number | 1336789130
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Entity Type | Individual
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Provider Name | SAMANTHA JEANNE WANNER
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Gender | Female
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Dates
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Enumeration Date | 01/09/2020
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Last Update Date | 11/25/2025
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Provider Practice Location Address
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Address Line | 3777 COON RAPIDS BLVD NW STE 120
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City | COON RAPIDS
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State | MN
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Zip | 55433-2630
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Country | US
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Telephone | 612-429-6686
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Fax |
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Provider Business Mailing Address
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Address Line | 3777 COON RAPIDS BLVD NW STE 120
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City | COON RAPIDS
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State | MN
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Zip | 55433-2630
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 0414
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License Number State | MN
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