Provider Demographics
NPI:1437635356
Name:WALKER, SAMANTHA (LADC-S)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:LADC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 OLD HUDSON RD APT 102
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4319
Mailing Address - Country:US
Mailing Address - Phone:612-459-3845
Mailing Address - Fax:
Practice Address - Street 1:1340 HAZEL ST N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4506
Practice Address - Country:US
Practice Address - Phone:763-339-7506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
MN30610101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker