Healthcare Provider Details

I. General information

NPI: 1245895002
Provider Name (Legal Business Name): LAKEN SHIREY ACMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 S FASHION BLVD
MURRAY UT
84107-6159
US

IV. Provider business mailing address

273 E MILLPOINT PL
SOUTH SALT LAKE UT
84115-4734
US

V. Phone/Fax

Practice location:
  • Phone: 801-875-2128
  • Fax:
Mailing address:
  • Phone: 801-503-7129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11106310-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: