Provider Demographics
NPI:1982083440
Name:DR AMY LYNN FEHLBERG
Entity Type:Organization
Organization Name:DR AMY LYNN FEHLBERG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FEHLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-901-0759
Mailing Address - Street 1:275 E SOUTH TEMPLE STE 340
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1246
Mailing Address - Country:US
Mailing Address - Phone:435-901-0759
Mailing Address - Fax:
Practice Address - Street 1:275 E SOUTH TEMPLE STE 340
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1246
Practice Address - Country:US
Practice Address - Phone:435-901-0759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5291247-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1619108057Medicaid
UT234049Medicare UPIN