Provider Demographics
NPI:1699139568
Name:AMETHYST CENTER FOR HEALING
Entity type:Organization
Organization Name:AMETHYST CENTER FOR HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-467-2863
Mailing Address - Street 1:1104 E ASHTON AVE
Mailing Address - Street 2:212
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4504
Mailing Address - Country:US
Mailing Address - Phone:801-467-2863
Mailing Address - Fax:
Practice Address - Street 1:1104 E ASHTON AVE
Practice Address - Street 2:212
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-4504
Practice Address - Country:US
Practice Address - Phone:801-467-2863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty