Healthcare Provider Details

I. General information

NPI: 1043743537
Provider Name (Legal Business Name): ETHAN CALEB AMDAHL PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62305 8TH ST.
CAMP PENDLETON CA
92055-5452
US

IV. Provider business mailing address

62305 8TH STREET
CAMP PENDLETON CA
92055-5452
US

V. Phone/Fax

Practice location:
  • Phone: 760-763-6058
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007593
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: