Provider Demographics
NPI:1164486080
Name:MATHIS, SHAWNERY
Entity Type:Individual
Prefix:MS
First Name:SHAWNERY
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 N WASHINGTON BLVD
Mailing Address - Street 2:#C304
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3913
Mailing Address - Country:US
Mailing Address - Phone:801-394-2096
Mailing Address - Fax:
Practice Address - Street 1:3600 MARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-3783
Practice Address - Country:US
Practice Address - Phone:801-394-2096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5913587-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist