Provider Demographics
NPI:1689082398
Name:PULVERMACHER, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PULVERMACHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:ND
Mailing Address - Zip Code:58730-0009
Mailing Address - Country:US
Mailing Address - Phone:701-965-6521
Mailing Address - Fax:701-965-6529
Practice Address - Street 1:200 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:ND
Practice Address - Zip Code:58730
Practice Address - Country:US
Practice Address - Phone:701-965-6521
Practice Address - Fax:701-965-6529
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4407104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND79419Medicaid