Provider Demographics
NPI:1245867167
Name:HALLGREN, SAMANTHA GRACE (MT-BC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GRACE
Last Name:HALLGREN
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3748 MCCRACKEN LN # A
Mailing Address - Street 2:
Mailing Address - City:ARDEN HILLS
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3229
Mailing Address - Country:US
Mailing Address - Phone:651-500-5422
Mailing Address - Fax:
Practice Address - Street 1:3748 MCCRACKEN LN # A
Practice Address - Street 2:
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112-3229
Practice Address - Country:US
Practice Address - Phone:651-500-5422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15322225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist