Healthcare Provider Details

I. General information

NPI: 1194326066
Provider Name (Legal Business Name): AMANDA KOCI CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date: 10/25/2024
Reactivation Date: 11/21/2024

III. Provider practice location address

5500 W BAGLEY PARK RD
WEST JORDAN UT
84081-5697
US

IV. Provider business mailing address

5500 W BAGLEY PARK RD
WEST JORDAN UT
84081-5697
US

V. Phone/Fax

Practice location:
  • Phone: 801-513-3125
  • Fax:
Mailing address:
  • Phone: 801-513-3125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11899068-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: