Provider Demographics
NPI:1275230468
Name:WOMELDORF, SAMANTHA (LADC, LPCC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WOMELDORF
Suffix:
Gender:F
Credentials:LADC, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1906
Mailing Address - Country:US
Mailing Address - Phone:952-856-3932
Mailing Address - Fax:952-448-6047
Practice Address - Street 1:1045 STOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2149
Practice Address - Country:US
Practice Address - Phone:952-448-6557
Practice Address - Fax:952-448-6047
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305744101YA0400X
MN3690101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)