=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659677219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRANCISCO XAVIER AMPUERO LA-SUDC; LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2011
-----------------------------------------------------
Last Update Date | 11/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 277 E 950 S
-----------------------------------------------------
City | OREM
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84058-5004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-691-0880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1366 SO. SLATE CANYON DR.
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-691-0880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 4953588-6006
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------