Provider Demographics
NPI:1205192218
Name:AMUNDSON, MILES (RAS)
Entity Type:Individual
Prefix:
First Name:MILES
Middle Name:
Last Name:AMUNDSON
Suffix:
Gender:M
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1147
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95963-4147
Mailing Address - Country:US
Mailing Address - Phone:530-865-1146
Mailing Address - Fax:530-865-6483
Practice Address - Street 1:1187 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:ORLAND
Practice Address - State:CA
Practice Address - Zip Code:95963-9136
Practice Address - Country:US
Practice Address - Phone:530-865-1146
Practice Address - Fax:530-865-6483
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1002101638101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)