MEDICARE: MR. B. SHANE HARMON 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	1041C0700X	Clinical Social Worker	141805-3501	UT

General Provider Information

NPI Number	:	1700882172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. B. SHANE HARMON LCSW

Provider Business Mailing Address
First Line	:	5149 S 1500 W
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3926
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

Provider Business Practice Location Address
First Line	:	5149 S 1500 W
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3926
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	07/27/2007

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