Healthcare Provider Details

I. General information

NPI: 1780515387
Provider Name (Legal Business Name): STACEY ANN SHAW PHD, CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8813 S REDWOOD RD STE B1
WEST JORDAN UT
84088-9272
US

IV. Provider business mailing address

3485 S FLEETWOOD DR
SALT LAKE CITY UT
84109-3284
US

V. Phone/Fax

Practice location:
  • Phone: 385-439-9823
  • Fax:
Mailing address:
  • Phone: 801-916-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7141593-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: