Provider Demographics
NPI:1255013488
Name:NELSON, SAMANTHA JO
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:NELSON
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 1:7826 CABANA CIR
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MN
Mailing Address - Zip Code:55353-9401
Mailing Address - Country:US
Mailing Address - Phone:320-434-3350
Mailing Address - Fax:
Practice Address - Street 1:314 10TH AVE S # 100
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1400
Practice Address - Country:US
Practice Address - Phone:612-767-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician