Provider Demographics
NPI:1245786847
Name:LEINEN, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:LEINEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 E BRAEBURN CIR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-4370
Mailing Address - Country:US
Mailing Address - Phone:605-359-4142
Mailing Address - Fax:
Practice Address - Street 1:201 EAST THIRTY-EIGHTH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-5898
Practice Address - Country:US
Practice Address - Phone:605-367-7924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD56680-1103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool