Provider Demographics
NPI:1689297095
Name:PARENTEAU, ANDRAYA THERESE
Entity Type:Individual
Prefix:
First Name:ANDRAYA
Middle Name:THERESE
Last Name:PARENTEAU
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 1:1720 BASSETT DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14445 COUNTY HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:56554-9121
Practice Address - Country:US
Practice Address - Phone:701-893-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZCY267454611261OtherBLUE CROSS BLUE SHIELD OF SOUTH CAROLINA