Provider Demographics
NPI:1780458745
Name:AMUNDSON, TAYLOR (LAC, LASAC)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:AMUNDSON
Suffix:
Gender:F
Credentials:LAC, LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8205 S PRIEST DR UNIT 12451
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-0175
Mailing Address - Country:US
Mailing Address - Phone:320-424-9604
Mailing Address - Fax:
Practice Address - Street 1:5540 W GLENDALE AVE STE C102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-2581
Practice Address - Country:US
Practice Address - Phone:623-248-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLASAC-15479101YA0400X
AZLAC-22446101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)