Provider Demographics
NPI:1053112615
Name:SAMPSON, AMORAY M
Entity type:Individual
Prefix:
First Name:AMORAY
Middle Name:M
Last Name:SAMPSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 CASON ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2843
Mailing Address - Country:US
Mailing Address - Phone:317-502-3512
Mailing Address - Fax:855-915-0244
Practice Address - Street 1:2785 CASON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2843
Practice Address - Country:US
Practice Address - Phone:765-446-4185
Practice Address - Fax:855-915-0244
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-24-392647106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician