Provider Demographics
NPI:1447738745
Name:RAY, SAMUEL NATHAN (RBT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:NATHAN
Last Name:RAY
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10273 YELLOW CIRCLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343
Mailing Address - Country:US
Mailing Address - Phone:952-401-9359
Mailing Address - Fax:
Practice Address - Street 1:1160 CENTRE POINTE DRIVE
Practice Address - Street 2:SUITE 7
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120
Practice Address - Country:US
Practice Address - Phone:952-401-9359
Practice Address - Fax:952-401-9805
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician