Provider Demographics
NPI:1619640406
Name:FAYE, SAMANTHA JANE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANE
Last Name:FAYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 MEADOWLANDS DR
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55127-2339
Mailing Address - Country:US
Mailing Address - Phone:612-268-6735
Mailing Address - Fax:
Practice Address - Street 1:1011 MEADOWLANDS DR
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-2339
Practice Address - Country:US
Practice Address - Phone:612-268-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other