Provider Demographics
NPI:1356863641
Name:TOSTESON, SAMUEL DAVID (LMFT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DAVID
Last Name:TOSTESON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 BALD EAGLE AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4711 BALD EAGLE AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3156
Practice Address - Country:US
Practice Address - Phone:651-587-7145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-09
Last Update Date:2017-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2697106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist