Provider Demographics
NPI:1164299087
Name:ISSAK, SAMAWADA
Entity Type:Individual
Prefix:
First Name:SAMAWADA
Middle Name:
Last Name:ISSAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 DONALD CT
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1753
Mailing Address - Country:US
Mailing Address - Phone:651-274-4536
Mailing Address - Fax:
Practice Address - Street 1:5501 FELTL RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-3944
Practice Address - Country:US
Practice Address - Phone:952-746-5350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician