Healthcare Provider Details

I. General information

NPI: 1679139083
Provider Name (Legal Business Name): EMILY CATHERINE SHEPARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date: 05/26/2026
Reactivation Date: 06/29/2026

III. Provider practice location address

5770 S 1500 W
SALT LAKE CITY UT
84123-5216
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-3412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number14243043-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: