Healthcare Provider Details

I. General information

NPI: 1659677219
Provider Name (Legal Business Name): FRANCISCO XAVIER AMPUERO LA-SUDC; LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2011
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 E 950 S
OREM UT
84058-5004
US

IV. Provider business mailing address

1366 SO. SLATE CANYON DR.
PROVO UT
84606
US

V. Phone/Fax

Practice location:
  • Phone: 801-691-0880
  • Fax:
Mailing address:
  • Phone: 801-691-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4953588-6006
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: