MEDICARE: SHANNON WEAVER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	5121600-3501	UT

General Provider Information

NPI Number	:	1053993501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON WEAVER LCSW

Provider Business Mailing Address
First Line	:	882 S 550 E
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-4547
Country	:	US
Telephone Number	:	801-631-7476
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 PINEBROOK RD STE 1250B
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5663
Country	:	US
Telephone Number	:	801-631-7476
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2021
Last Update Date	:	04/24/2021

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