Healthcare Provider Details

I. General information

NPI: 1831052976
Provider Name (Legal Business Name): AMIE MAHAVANH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39639 OLD HIGHWAY 80
BOULEVARD CA
91905-9733
US

IV. Provider business mailing address

39639 OLD HIGHWAY 80
BOULEVARD CA
91905-9733
US

V. Phone/Fax

Practice location:
  • Phone: 619-766-4655
  • Fax:
Mailing address:
  • Phone: 619-766-4655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number240145966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: