Healthcare Provider Details

I. General information

NPI: 1336959295
Provider Name (Legal Business Name): AMELIE JUSTINE ZICHY-THYSSEN MFT, CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2025
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7070 S UNION PARK AVE
MIDVALE UT
84047-4179
US

IV. Provider business mailing address

2485 SILVER CLOUD DR
PARK CITY UT
84060-7052
US

V. Phone/Fax

Practice location:
  • Phone: 801-528-7309
  • Fax:
Mailing address:
  • Phone: 949-441-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14193003-6009
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number14193003-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: