Healthcare Provider Details

I. General information

NPI: 1609987957
Provider Name (Legal Business Name): SHELLY EYRE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLY EYRE LCSW

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3051 W MAPLE LOOP DR SUITE 201
LEHI UT
84043-5621
US

IV. Provider business mailing address

PO BOX 28128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-824-0722
  • Fax: 801-341-8218
Mailing address:
  • Phone: 801-824-0722
  • Fax: 801-341-8218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1393513501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number139351-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: