Provider Demographics
NPI:1750783783
Name:BROWN, AMY NICHOLE (LCMHC LASUDC LCAS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICHOLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:LCMHC LASUDC LCAS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:NICHOLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCAS
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:801-373-4670
Mailing Address - Fax:
Practice Address - Street 1:1185 E 300 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3539
Practice Address - Country:US
Practice Address - Phone:801-852-4472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT310249-6008101YA0400X
NC23883101YA0400X
NC11750101YM0800X, 101YP2500X
UT310249-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT310249-6008OtherSTATE OF UTAH DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING
NC11750OtherNORTH CAROLINA BOARD OF LICENSED PROFESSIONAL COUNSELORS
NC23883OtherNORTH CAROLINA SUBSTANCE ABUSE PROFESSIONAL PRACTICE BOARD
UT310249-6004OtherSTATE OF UTAH DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING