Provider Demographics
NPI:1689368078
Name:MOUACHEUPAO, SAMANNTHA (LMFT)
Entity Type:Individual
Prefix:
First Name:SAMANNTHA
Middle Name:
Last Name:MOUACHEUPAO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 WAYZATA BLVD STE 340
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1365
Mailing Address - Country:US
Mailing Address - Phone:763-566-0088
Mailing Address - Fax:763-566-0089
Practice Address - Street 1:8401 WAYZATA BLVD STE 340
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1365
Practice Address - Country:US
Practice Address - Phone:763-566-0088
Practice Address - Fax:763-566-0089
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4318106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist