Healthcare Provider Details

I. General information

NPI: 1003615113
Provider Name (Legal Business Name): AMANDA NICOLE STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2025
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 N STATE ST
OREM UT
84057-2025
US

IV. Provider business mailing address

1790 N STATE ST
OREM UT
84057-2025
US

V. Phone/Fax

Practice location:
  • Phone: 888-224-8250
  • Fax: 801-224-8301
Mailing address:
  • Phone: 888-224-8250
  • Fax: 801-224-8301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13082152-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: