Provider Demographics
NPI:1194198010
Name:AMETHYST CENTER FOR HEALING
Entity Type:Organization
Organization Name:AMETHYST CENTER FOR HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER/CO-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:FULMER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:435-640-7466
Mailing Address - Street 1:PO BOX 526391
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84152-6391
Mailing Address - Country:US
Mailing Address - Phone:801-467-2863
Mailing Address - Fax:
Practice Address - Street 1:124 S 400 E STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-5307
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:2015-11-02
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty