Provider Demographics
NPI:1427359611
Name:NELSEN, AMANDA JILL (MED, LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JILL
Last Name:NELSEN
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1262 W 12700 S
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7798
Mailing Address - Country:US
Mailing Address - Phone:801-302-8146
Mailing Address - Fax:
Practice Address - Street 1:1262 W 12700 S
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7798
Practice Address - Country:US
Practice Address - Phone:801-302-8146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7022103-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health