Provider Demographics
NPI:1619597192
Name:ST MARIE, SAMUEL DOUGLAS
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DOUGLAS
Last Name:ST MARIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 VALLEY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1751
Mailing Address - Country:US
Mailing Address - Phone:612-423-4560
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-423-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN211701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical