Healthcare Provider Details

I. General information

NPI: 1649055385
Provider Name (Legal Business Name): MILES CLARK RAYMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 CALIFORNIA ST
EUREKA CA
95501-2808
US

IV. Provider business mailing address

2255 COCHRAN RD
MCKINLEYVILLE CA
95519-7922
US

V. Phone/Fax

Practice location:
  • Phone: 707-443-7358
  • Fax:
Mailing address:
  • Phone: 707-499-9157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number148566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: