Healthcare Provider Details

I. General information

NPI: 1780458745
Provider Name (Legal Business Name): TAYLOR AMUNDSON LAC, LASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 W GLENDALE AVE STE C102
GLENDALE AZ
85301-2581
US

IV. Provider business mailing address

8205 S PRIEST DR UNIT 12451
TEMPE AZ
85284-0175
US

V. Phone/Fax

Practice location:
  • Phone: 623-248-0283
  • Fax:
Mailing address:
  • Phone: 320-424-9604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-22446
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLASAC-15479
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: