MEDICARE: SAMANTHA E SIMON MA, LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	CC01336	MN

General Provider Information

NPI Number	:	1174066997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA E SIMON MA, LPCC

Provider Business Mailing Address
First Line	:	6063 HUDSON RD
Second Line	:	SUITE 200
City	:	WOODBURY
State	:	MN
Zip	:	55125-4454
Country	:	US
Telephone Number	:	952-460-9053
Fax Number	:	651-714-9029

Provider Business Practice Location Address
First Line	:	6063 HUDSON RD
Second Line	:	SUITE 200
City	:	WOODBURY
State	:	MN
Zip	:	55125-4454
Country	:	US
Telephone Number	:	952-460-9053
Fax Number	:	651-714-9029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2016
Last Update Date	:	11/28/2016

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