Active NPI
Samuel Bomber, LPCC
- Mental Health Counselor
- Minnetonka, MN
National Provider Identifier
1700422276
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 2272
- Practice address
- 10273 Yellow Circle Dr
Minnetonka, MN 55343-9144 - Phone
- (952) 215-3756
- NPI assigned
- Nov 20, 2019
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 2272 | MN | Primary |
Addresses
Primary practice location
10273 Yellow Circle Dr
Minnetonka, MN 55343-9144
Mailing address
10273 Yellow Circle Dr
Minnetonka, MN 55343-9144
Phone (952) 215-3756
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2272 | MN | MD | Marriage & Family Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Secure Base Counseling Center LLC | Multi-Specialty | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1574208000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1648512000000",
"number": "1700422276",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10273 YELLOW CIRCLE DR",
"city": "MINNETONKA",
"state": "MN",
"postal_code": "553439144",
"telephone_number": "952-215-3756"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10273 YELLOW CIRCLE DR",
"city": "MINNETONKA",
"state": "MN",
"postal_code": "553439144",
"telephone_number": "952-215-3756"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOMBER",
"first_name": "SAMUEL",
"credential": "LPCC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2019-11-20",
"last_updated": "2022-03-29",
"certification_date": "2022-03-29",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Counselor, Mental Health",
"state": "MN",
"license": "2272",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minnetonka, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 29, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.