Healthcare Provider Details

I. General information

NPI: 1700372018
Provider Name (Legal Business Name): SAMANTHA ANN FORSYTHE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 E 700 S
AMERICAN FORK UT
84003-3366
US

IV. Provider business mailing address

3725 W 4100 S STE 201
WEST VALLEY CITY UT
84120-5427
US

V. Phone/Fax

Practice location:
  • Phone: 801-284-4950
  • Fax:
Mailing address:
  • Phone: 888-949-4864
  • Fax: 801-375-9225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number316156-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: