MEDICARE: SANDSTED WELLNESS LLC

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

General Provider Information

NPI Number	:	1780553925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDSTED WELLNESS LLC

Provider Business Mailing Address
First Line	:	2005 ALOHA AVE
Second Line	:
City	:	SHAKOPEE
State	:	MN
Zip	:	55379-7732
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20855 KENSINGTON BLVD STE B201
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-7542
Country	:	US
Telephone Number	:	612-812-1875
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SAMANTHA SANDER WOMELDORF
Credential	:	LADC, LPCC
Telephone Number	:	612-812-1875

Provider Enumeration Date	:	11/04/2025
Last Update Date	:	11/04/2025

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