MEDICARE: ANDRAYA THERESE PARENTEAU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZCY267454611261	OTHER		BLUE CROSS BLUE SHIELD OF SOUTH CAROLINA

General Provider Information

NPI Number	:	1689297095
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRAYA THERESE PARENTEAU

Provider Business Mailing Address
First Line	:	1720 BASSETT DR
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-6569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14445 COUNTY HIGHWAY 5
Second Line	:
City	:	LAKE PARK
State	:	MN
Zip	:	56554-9121
Country	:	US
Telephone Number	:	701-893-8166
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2020
Last Update Date	:	05/20/2020

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Directions to “ ANDRAYA THERESE PARENTEAU ” Practice Location

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