Basic Information
Provider Information | |||||||||
NPI: | 1922387950 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEAUCHMAN | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2168 | ||||||||
Address2: |   | ||||||||
City: | FARGO | ||||||||
State: | ND | ||||||||
PostalCode: | 581072168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012342119 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 2ND AVE NE | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | ND | ||||||||
PostalCode: | 584013373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012534000 | ||||||||
FaxNumber: | 7019526019 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2011 | ||||||||
LastUpdateDate: | 09/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1400 | KS | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | LP5687 | MN | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 497 | ND | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 1922387950 | 05 | MN |   | MEDICAID | 17563 | 05 | ND |   | MEDICAID |