Healthcare Provider Details

I. General information

NPI: 1437931391
Provider Name (Legal Business Name): NATHAN BRENT SHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 W SOUTH JORDAN PKWY STE D
SOUTH JORDAN UT
84095-5519
US

IV. Provider business mailing address

1206 W SOUTH JORDAN PKWY STE D
SOUTH JORDAN UT
84095-5519
US

V. Phone/Fax

Practice location:
  • Phone: 801-302-3801
  • Fax: 801-302-7248
Mailing address:
  • Phone: 801-302-3801
  • Fax: 801-302-7248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14290543-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: