Provider Demographics
NPI:1376323519
Name:SIDWELL, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:SIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738-6162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 N 1680 E STE T2
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2573
Practice Address - Country:US
Practice Address - Phone:435-218-5953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5342993-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical