Healthcare Provider Details

I. General information

NPI: 1447123740
Provider Name (Legal Business Name): SOPHIE MICKELSEN ACMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

963 S 1170 E
SPANISH FORK UT
84660-2640
US

IV. Provider business mailing address

963 S 1170 E
SPANISH FORK UT
84660-2640
US

V. Phone/Fax

Practice location:
  • Phone: 801-472-4630
  • Fax:
Mailing address:
  • Phone: 801-472-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14202553-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: