Provider Demographics
NPI:1124348982
Name:AMIS, CAROLINE (LSAC)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:AMIS
Suffix:
Gender:F
Credentials:LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 S 500 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1002
Mailing Address - Country:US
Mailing Address - Phone:801-428-3419
Mailing Address - Fax:801-355-4607
Practice Address - Street 1:450 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2981
Practice Address - Country:US
Practice Address - Phone:801-587-2770
Practice Address - Fax:801-355-4607
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7210961-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical