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General NPI Number Information
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NPI Number | 1023366127
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Entity Type | Individual
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Provider Name | SHANNON LOUISE VANDERKOOI L.C.S.W.
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Gender | Female
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Dates
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Enumeration Date | 08/21/2012
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Last Update Date | 08/21/2012
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Provider Practice Location Address
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Address Line | 5698 W GLEN EAGLE DR
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City | WEST VALLEY CITY
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State | UT
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Zip | 84128-4013
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Country | US
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Telephone | 801-969-4181
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Fax |
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Provider Business Mailing Address
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Address Line | 6671 W HAVEN MAPLE DR
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City | WEST JORDAN
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State | UT
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Zip | 84081-2957
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Country | US
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Telephone | 801-304-0943
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 54237883501
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License Number State | UT
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