Provider Demographics
NPI:1093467524
Name:WILLETT, AMANDA (CSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILLETT
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E 2200 N APT E302
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-4726
Mailing Address - Country:US
Mailing Address - Phone:708-606-3994
Mailing Address - Fax:
Practice Address - Street 1:115 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-0115
Practice Address - Country:US
Practice Address - Phone:708-606-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11797514-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker