Healthcare Provider Details

I. General information

NPI: 1336849017
Provider Name (Legal Business Name): EDWARD LAWRENCE JOONG SHIN II LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1458 E 820 N
OREM UT
84097-5481
US

IV. Provider business mailing address

1538 S 175 E
OREM UT
84058-7694
US

V. Phone/Fax

Practice location:
  • Phone: 801-389-7169
  • Fax:
Mailing address:
  • Phone: 949-295-3964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12675017-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: