Provider Demographics
NPI:1942929567
Name:SCHULLO, SAMANTHA JOAN (MSW, LGSW, LADC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JOAN
Last Name:SCHULLO
Suffix:
Gender:F
Credentials:MSW, LGSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 BLAISDELL AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2415
Mailing Address - Country:US
Mailing Address - Phone:612-286-0473
Mailing Address - Fax:
Practice Address - Street 1:2118 BLAISDELL AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2415
Practice Address - Country:US
Practice Address - Phone:612-286-0473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306452101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)