Healthcare Provider Details

I. General information

NPI: 1326693276
Provider Name (Legal Business Name): ELLEN SHAPIRO CAMPBELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 N UNIVERSITY AVE STE 100
PROVO UT
84604-3819
US

IV. Provider business mailing address

2520 N UNIVERSITY AVE STE 100
PROVO UT
84604-3819
US

V. Phone/Fax

Practice location:
  • Phone: 385-567-4063
  • Fax: 385-567-4063
Mailing address:
  • Phone: 385-567-4063
  • Fax: 385-567-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8614388-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: