Healthcare Provider Details

I. General information

NPI: 1639980402
Provider Name (Legal Business Name): AMIYAH KAY MAYO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 BIELENBERG DR
WOODBURY MN
55125-1700
US

IV. Provider business mailing address

7416 COLUMBIA CT
WOODBURY MN
55125-1669
US

V. Phone/Fax

Practice location:
  • Phone: 612-439-4653
  • Fax:
Mailing address:
  • Phone: 763-485-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: