Provider Demographics
NPI:1164289005
Name:IVERSON, SAMANTHA (LMFT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:IVERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 MAINSTREET STE 2A
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7408
Mailing Address - Country:US
Mailing Address - Phone:612-756-8353
Mailing Address - Fax:
Practice Address - Street 1:1605 MAINSTREET STE 2A
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-7408
Practice Address - Country:US
Practice Address - Phone:612-756-8353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4081106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist