Healthcare Provider Details

I. General information

NPI: 1508534892
Provider Name (Legal Business Name): CAROLYN LOUISE FJELDSTED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 N 1200 W
OREM UT
84057-2449
US

IV. Provider business mailing address

1447 N 1200 W
OREM UT
84057-2449
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-5450
  • Fax:
Mailing address:
  • Phone: 801-655-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5976073-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: