Provider Demographics
NPI:1760143630
Name:NIELSEN, SUNNY LEE (CMHC)
Entity Type:Individual
Prefix:
First Name:SUNNY
Middle Name:LEE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 65 BOX 510008
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:UT
Mailing Address - Zip Code:84051-9700
Mailing Address - Country:US
Mailing Address - Phone:801-209-6108
Mailing Address - Fax:
Practice Address - Street 1:20428 W 6250 N
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:UT
Practice Address - Zip Code:84051-8405
Practice Address - Country:US
Practice Address - Phone:801-209-6108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5265255-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health