Healthcare Provider Details

I. General information

NPI: 1215890108
Provider Name (Legal Business Name): SHELLY -ANN TAMARA FOSTER-COULSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH HARRIS

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4179 S RIVERBOAT RD STE 240
MURRAY UT
84123-2986
US

IV. Provider business mailing address

4179 S RIVERBOAT RD STE 240
MURRAY UT
84123-2986
US

V. Phone/Fax

Practice location:
  • Phone: 919-971-8744
  • Fax:
Mailing address:
  • Phone: 919-971-8744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA22304
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: