Healthcare Provider Details

I. General information

NPI: 1194198010
Provider Name (Legal Business Name): AMETHYST CENTER FOR HEALING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 S 400 E STE 300
SALT LAKE CITY UT
84111-5307
US

IV. Provider business mailing address

PO BOX 526391
SALT LAKE CITY UT
84152-6391
US

V. Phone/Fax

Practice location:
  • Phone: 801-467-2863
  • Fax:
Mailing address:
  • Phone: 801-467-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JANA CLAIRE FULMER
Title or Position: CO-FOUNDER/CO-DIRECTOR
Credential: LPC
Phone: 435-640-7466