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General NPI Number Information
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NPI Number | 1841708963
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Entity Type | Individual
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Provider Name | AMY M WILDE ACMHC, LSUDC
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Gender | Female
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Dates
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Enumeration Date | 01/11/2018
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Last Update Date | 01/11/2018
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Provider Practice Location Address
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Address Line | 20 S STATE ST
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City | LINDON
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State | UT
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Zip | 84042-1939
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Country | US
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Telephone | 801-441-7144
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Fax |
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Provider Business Mailing Address
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Address Line | 10442 S SAGE CREEK RD
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City | SOUTH JORDAN
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State | UT
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Zip | 84009-3909
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Country | US
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Telephone | 801-637-9771
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 302808-6006
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 302808-6009
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License Number State | UT
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