Provider Demographics
NPI:1841708963
Name:WILDE, AMY M (ACMHC, LSUDC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:WILDE
Suffix:
Gender:F
Credentials:ACMHC, LSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10442 S SAGE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-3909
Mailing Address - Country:US
Mailing Address - Phone:801-637-9771
Mailing Address - Fax:
Practice Address - Street 1:20 S STATE ST
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1939
Practice Address - Country:US
Practice Address - Phone:801-441-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT302808-6006101YA0400X
UT302808-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)