Provider Demographics
NPI:1154712123
Name:WHITTAKER, AMY LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 W BAGLEY PARK RD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-5697
Mailing Address - Country:US
Mailing Address - Phone:801-282-1027
Mailing Address - Fax:801-282-1182
Practice Address - Street 1:5500 W BAGLEY PARK RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84081-5697
Practice Address - Country:US
Practice Address - Phone:801-282-1027
Practice Address - Fax:801-282-1182
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5225527-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical