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NPI Code Detail

MEDICARE: KATHLEEN ANN SAMILO MA, LP

MEDICARE: KATHLEEN ANN SAMILO MA, LP
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
1103T00000XPsychologistLP 0249MN

General Provider Information

NPI Number : 1376655761
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATHLEEN ANN SAMILO MA, LP
Provider Business Mailing Address
First Line : 1485 81ST AVE NE
Second Line :
City : SPRING LAKE PARK
State : MN
Zip : 55432-2111
Country : US
Telephone Number : 763-780-3036
Fax Number :
Provider Business Practice Location Address
First Line : 1867 SAINT CLAIR AVE
Second Line :
City : SAINT PAUL
State : MN
Zip : 55105-1642
Country : US
Telephone Number : 651-402-3458
Fax Number : 763-780-0784
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2006
Last Update Date : 07/08/2007

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Directions to “ KATHLEEN ANN SAMILO MA, LP” Practice Location

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