Provider Demographics
NPI:1922387950
Name:BEAUCHMAN, SAMANTHA LYNN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:BEAUCHMAN
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 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3373
Practice Address - Country:US
Practice Address - Phone:701-253-4000
Practice Address - Fax:701-952-6019
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1400103T00000X
MNLP5687103T00000X
ND497103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1922387950Medicaid
ND17563Medicaid
ND17563Medicaid