Healthcare Provider Details

I. General information

NPI: 1821282419
Provider Name (Legal Business Name): SHANE FLANNERY HURST MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 26TH ST
OGDEN UT
84401-3105
US

IV. Provider business mailing address

237 26TH ST
OGDEN UT
84401-3105
US

V. Phone/Fax

Practice location:
  • Phone: 801-625-3700
  • Fax:
Mailing address:
  • Phone: 801-625-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6586446-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: