Provider Demographics
NPI:1457991549
Name:WELLMAN, SAMUEL PAUL (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PAUL
Last Name:WELLMAN
Suffix:
Gender:M
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TWELVE OAKS CENTER DR STE 642H
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4512
Mailing Address - Country:US
Mailing Address - Phone:952-451-7267
Mailing Address - Fax:
Practice Address - Street 1:600 TWELVE OAKS CENTER DR STE 642H
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4512
Practice Address - Country:US
Practice Address - Phone:952-451-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2330101YM0800X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health