Provider Demographics
NPI:1497300644
Name:RAY, AMANDA GRACE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:GRACE
Last Name:RAY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:GRACE
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 NORTH MAIN STREET
Mailing Address - Street 2:1A
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313
Mailing Address - Country:US
Mailing Address - Phone:912-924-4055
Mailing Address - Fax:866-467-4321
Practice Address - Street 1:360 N. MAIN STREET
Practice Address - Street 2:1A
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313
Practice Address - Country:US
Practice Address - Phone:912-294-4055
Practice Address - Fax:866-467-4321
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TXRBT-19-96862106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician