Healthcare Provider Details

I. General information

NPI: 1942085022
Provider Name (Legal Business Name): SHASTA REBALKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 S 500 E STE 6
OGDEN UT
84405-6955
US

IV. Provider business mailing address

5300 S 500 E STE 6
OGDEN UT
84405-6955
US

V. Phone/Fax

Practice location:
  • Phone: 801-392-0942
  • Fax:
Mailing address:
  • Phone: 801-392-0942
  • Fax: 801-392-0942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: