MEDICARE: KARL E SEASHORE M.S., L.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	362944-6004	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	66020	OTHER	UT	UNI BEHAVIORAL HEALTH NET

General Provider Information

NPI Number	:	1518934744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARL E SEASHORE M.S., L.P.C.

Provider Business Mailing Address
First Line	:	4190 HIGHLAND DR
Second Line	:	SUITE 211
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2600
Country	:	US
Telephone Number	:	801-272-0613
Fax Number	:	801-272-0678

Provider Business Practice Location Address
First Line	:	4190 HIGHLAND DR
Second Line	:	SUITE 211
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2600
Country	:	US
Telephone Number	:	801-272-0613
Fax Number	:	801-272-0678

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	07/08/2007

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