Provider Demographics
NPI:1821068966
Name:SAMUELSON, WAYNE D (PHD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:D
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 PAGE DR S STE 105
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3536
Mailing Address - Country:US
Mailing Address - Phone:701-893-3419
Mailing Address - Fax:
Practice Address - Street 1:1351 PAGE DR S STE 105
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3536
Practice Address - Country:US
Practice Address - Phone:701-893-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND75103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S67133Medicare UPIN