Healthcare Provider Details

I. General information

NPI: 1417468497
Provider Name (Legal Business Name): BOBBETTE SPRAGUE SHEPARD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2017
Last Update Date: 10/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 E 900 N
RICHFIELD UT
84701-1845
US

IV. Provider business mailing address

535 W 300 N
RICHFIELD UT
84701-2017
US

V. Phone/Fax

Practice location:
  • Phone: 435-890-0359
  • Fax: 435-893-0357
Mailing address:
  • Phone: 435-201-1735
  • Fax: 435-893-0357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116040-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: