MEDICARE: SHANNALEE OTANEZ LCSW

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	1041C0700X	Clinical Social Worker	10347309-3501	UT

General Provider Information

NPI Number	:	1700255031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNALEE OTANEZ LCSW

Provider Business Mailing Address
First Line	:	1554 W PARADISE LN
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84123-4355
Country	:	US
Telephone Number	:	801-554-0663
Fax Number	:

Provider Business Practice Location Address
First Line	:	124 S 400 E STE 250
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-5315
Country	:	US
Telephone Number	:	435-774-0485
Fax Number	:

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

Provider Enumeration Date	:	09/16/2015
Last Update Date	:	07/02/2020

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