Basic Information
| Provider Information | |||||||||
| NPI: | 1679006191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMIR | ||||||||
| FirstName: | RAPHAEL | ||||||||
| MiddleName: | KADOORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99 | ||||||||
| Address2: | |||||||||
| City: | MARIPOSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953380099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099662000 | ||||||||
| FaxNumber: | 2097420996 | ||||||||
| Practice Location | |||||||||
| Address1: | 5362 LEMEE LN | ||||||||
| Address2: | |||||||||
| City: | MARIPOSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953389556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099662000 | ||||||||
| FaxNumber: | 2097420996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2017 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 117377 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YP2500X | 7416 | CA | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.