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General NPI Number Information
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NPI Number | 1063303717
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Entity Type | Individual
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Provider Name | SHELLY JO WAHLSTROM CHT, PHD
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Gender | Female
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Dates
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Enumeration Date | 07/11/2025
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Last Update Date | 07/11/2025
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Provider Practice Location Address
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Address Line | 2827 W 4400 S
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City | ROY
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State | UT
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Zip | 84067-8951
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Country | US
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Telephone | 801-643-3211
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Fax |
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Provider Business Mailing Address
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Address Line | 2827 W 4400 S
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City | ROY
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State | UT
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Zip | 84067-8951
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Country | US
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Telephone | 801-643-3211
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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 | 374K00000X
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Taxonomy Name | Religious Nonmedical Practitioner
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License Number | 374K00000X
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License Number State | AZ
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