Provider Demographics
NPI:1245311901
Name:SAMPSON, KATHLEEN LOUISE (MSW,LICSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LOUISE
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:MSW,LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 39TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1847
Mailing Address - Country:US
Mailing Address - Phone:612-724-2532
Mailing Address - Fax:
Practice Address - Street 1:2239 CARTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1638
Practice Address - Country:US
Practice Address - Phone:612-722-5120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN73391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19767Medicaid