Healthcare Provider Details

I. General information

NPI: 1184124992
Provider Name (Legal Business Name): SHERSTIN FIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 W SOUTH JORDAN PKWY STE 202
SOUTH JORDAN UT
84095-4712
US

IV. Provider business mailing address

14640 S 1690 W
BLUFFDALE UT
84065-3763
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-1155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9268722-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: