Provider Demographics
NPI:1326654617
Name:EVANS, SAMANTHA MARCINETTE (MS, LPCC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARCINETTE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 SE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3681
Mailing Address - Country:US
Mailing Address - Phone:218-380-7310
Mailing Address - Fax:218-999-7068
Practice Address - Street 1:4225 TECHNOLOGY DR NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5118
Practice Address - Country:US
Practice Address - Phone:218-751-0281
Practice Address - Fax:218-751-0870
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02579101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health