Provider Demographics
NPI:1073585170
Name:SAMPLES SIEGEL, CHRISTINE S (LP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:S
Last Name:SAMPLES SIEGEL
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:SAMPLES
Other - Last Name:BARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LP
Mailing Address - Street 1:5100 EDEN AV
Mailing Address - Street 2:STE 110
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55436
Mailing Address - Country:US
Mailing Address - Phone:952-746-4780
Mailing Address - Fax:952-746-4252
Practice Address - Street 1:5100 EDEN AV
Practice Address - Street 2:STE 110
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55436
Practice Address - Country:US
Practice Address - Phone:952-746-4780
Practice Address - Fax:952-746-4252
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 2583103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist