MEDICARE: SAMANTHA GRAY MA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1932932878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA GRAY MA

Provider Business Mailing Address
First Line	:	753 GENEVA PKWY N UNIT 2
Second Line	:
City	:	LAKE GENEVA
State	:	WI
Zip	:	53147-4579
Country	:	US
Telephone Number	:	224-772-3412
Fax Number	:

Provider Business Practice Location Address
First Line	:	753 GENEVA PKWY N UNIT 2
Second Line	:
City	:	LAKE GENEVA
State	:	WI
Zip	:	53147-4579
Country	:	US
Telephone Number	:	262-812-0605
Fax Number	:

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

Provider Enumeration Date	:	08/26/2024
Last Update Date	:	11/05/2025

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