MEDICARE: MR. SAMUEL JOSEPH MURRAY JR.

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

General Provider Information

NPI Number	:	1720821044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMUEL JOSEPH MURRAY JR.

Provider Business Mailing Address
First Line	:	2911 W GRAND BLVD APT 5101
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-2684
Country	:	US
Telephone Number	:	336-350-2454
Fax Number	:

Provider Business Practice Location Address
First Line	:	2911 W GRAND BLVD APT 5101
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-2684
Country	:	US
Telephone Number	:	336-350-2454
Fax Number	:

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

Provider Enumeration Date	:	06/14/2024
Last Update Date	:	06/14/2024

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