MEDICARE: SAMUEL DAVID TOSTESON LMFT

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	106H00000X	Marriage & Family Therapist	2697	MN

General Provider Information

NPI Number	:	1356863641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL DAVID TOSTESON LMFT

Provider Business Mailing Address
First Line	:	4711 BALD EAGLE AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4711 BALD EAGLE AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3156
Country	:	US
Telephone Number	:	651-587-7145
Fax Number	:

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

Provider Enumeration Date	:	07/09/2017
Last Update Date	:	07/09/2017

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