Healthcare Provider Details

I. General information

NPI: 1376351049
Provider Name (Legal Business Name): SHAUNA LIGHT ACHMC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2024
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 W CENTER ST
OREM UT
84057-5207
US

IV. Provider business mailing address

852 W 1560 N
OREM UT
84057-2957
US

V. Phone/Fax

Practice location:
  • Phone: 801-903-5903
  • Fax:
Mailing address:
  • Phone: 801-787-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13788659-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: