Provider Demographics
NPI:1174738215
Name:SAMPSON PA
Entity type:Organization
Organization Name:SAMPSON PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:N
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD LICENSED PSYCHOL
Authorized Official - Phone:218-262-4453
Mailing Address - Street 1:225 1ST ST N
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792
Mailing Address - Country:US
Mailing Address - Phone:218-741-3740
Mailing Address - Fax:
Practice Address - Street 1:914 MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746
Practice Address - Country:US
Practice Address - Phone:218-262-4453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1373103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6118559OtherUBH
MN8L848SAOtherBCBS