Provider Demographics
NPI:1649055385
Name:RAYMER, MILES CLARK
Entity type:Individual
Prefix:
First Name:MILES
Middle Name:CLARK
Last Name:RAYMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 COCHRAN RD
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-7922
Mailing Address - Country:US
Mailing Address - Phone:707-499-9157
Mailing Address - Fax:
Practice Address - Street 1:1802 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-2808
Practice Address - Country:US
Practice Address - Phone:707-443-7358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA148566106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program