Healthcare Provider Details

I. General information

NPI: 1518775063
Provider Name (Legal Business Name): AMANDA WATERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 250 E STE G50
MURRAY UT
84107-6165
US

IV. Provider business mailing address

PO BOX 25537
SALT LAKE CITY UT
84125-0537
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number14031489-4104
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: