Healthcare Provider Details

I. General information

NPI: 1700882172
Provider Name (Legal Business Name): B. SHANE HARMON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5149 S 1500 W
RIVERDALE UT
84405-3926
US

IV. Provider business mailing address

5149 S 1500 W
RIVERDALE UT
84405-3926
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-0402
  • Fax: 801-475-7464
Mailing address:
  • Phone: 801-475-0402
  • Fax: 801-475-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number141805-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: