Provider Demographics
NPI:1669573994
Name:WITHERS, TAMERA NICOLE (SSW)
Entity type:Individual
Prefix:
First Name:TAMERA
Middle Name:NICOLE
Last Name:WITHERS
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:TAMERA
Other - Middle Name:NICOLE
Other - Last Name:HARMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:WEBB
Mailing Address - Street 1:750 N FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:
Practice Address - Street 1:750 N FREEDOM BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1690
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6053799-3503104100000X
UT6053799-6009101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program