Healthcare Provider Details

I. General information

NPI: 1992132971
Provider Name (Legal Business Name): MRS. AMBERLEE ALISSA SHEPHERD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 E 1800 N
NORTH LOGAN UT
84341-2019
US

IV. Provider business mailing address

1484 N 1600 E
LOGAN UT
84341-2910
US

V. Phone/Fax

Practice location:
  • Phone: 435-213-3062
  • Fax:
Mailing address:
  • Phone: 435-881-9170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: