Healthcare Provider Details

I. General information

NPI: 1437690245
Provider Name (Legal Business Name): SHAWN MANSELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12608 S 125 W STE E
DRAPER UT
84020-8437
US

IV. Provider business mailing address

12608 S 125 W STE E
DRAPER UT
84020-8437
US

V. Phone/Fax

Practice location:
  • Phone: 801-499-4179
  • Fax:
Mailing address:
  • Phone: 801-810-1119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number89940743501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: