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NPI Code Detail

MEDICARE: NICOLE SHAW

MEDICARE: NICOLE SHAW
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
1101YM0800XMental Health Counselor10403016-3502UT

General Provider Information

NPI Number : 1861910549
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE SHAW
Provider Business Mailing Address
First Line : 1003 W ROOFTOP DR
Second Line :
City : MIDVALE
State : UT
Zip : 84047-4805
Country : US
Telephone Number : 703-732-4531
Fax Number :
Provider Business Practice Location Address
First Line : 2450 E FORT UNION BLVD
Second Line :
City : COTTONWOOD HEIGHTS
State : UT
Zip : 84121-3337
Country : US
Telephone Number : 801-669-5888
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/01/2017
Last Update Date : 03/17/2018

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Directions to “ NICOLE SHAW ” Practice Location

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