Provider Demographics
NPI:1164203667
Name:AMOSA, SAIMOA SAM (AA, AS, BA)
Entity Type:Individual
Prefix:
First Name:SAIMOA
Middle Name:SAM
Last Name:AMOSA
Suffix:
Gender:M
Credentials:AA, AS, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 REDDINGTON LN APT 132
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3458
Mailing Address - Country:US
Mailing Address - Phone:801-739-5575
Mailing Address - Fax:
Practice Address - Street 1:2880 W 3650 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3743
Practice Address - Country:US
Practice Address - Phone:801-943-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty