Provider Demographics
NPI:1801430277
Name:KALLBERG, SAMANTHA MARIE (PSYD, LP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:KALLBERG
Suffix:
Gender:
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23629 INGA AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:MN
Mailing Address - Zip Code:55031-9776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23629 INGA AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:MN
Practice Address - Zip Code:55031-9776
Practice Address - Country:US
Practice Address - Phone:218-590-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6987103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling