Healthcare Provider Details

I. General information

NPI: 1831230259
Provider Name (Legal Business Name): STEPHEN SHEPPARD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E 1R52 SOM
SALT LAKE CITY UT
84132-2119
US

IV. Provider business mailing address

2840 CANYON VIEW DR
SALT LAKE CITY UT
84109-2005
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-6228
  • Fax: 801-585-6702
Mailing address:
  • Phone: 801-581-6228
  • Fax: 801-585-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number353104-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number353104-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: