Healthcare Provider Details

I. General information

NPI: 1225755887
Provider Name (Legal Business Name): AMANDA JOY RAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA J TYLER

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60110 FOOTHILL RD
ST IGNATIUS MT
59865-9161
US

IV. Provider business mailing address

60110 FOOTHILL RD
ST IGNATIUS MT
59865-9161
US

V. Phone/Fax

Practice location:
  • Phone: 617-653-4551
  • Fax:
Mailing address:
  • Phone: 617-653-4551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number90211
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: