Provider Demographics
NPI:1346602133
Name:MICHAEL, SHANDI
Entity Type:Individual
Prefix:
First Name:SHANDI
Middle Name:
Last Name:MICHAEL
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 1:286 N STATE ST # 357
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN GREEN
Mailing Address - State:UT
Mailing Address - Zip Code:84632-7701
Mailing Address - Country:US
Mailing Address - Phone:801-903-5903
Mailing Address - Fax:
Practice Address - Street 1:286 N STATE ST # 357
Practice Address - Street 2:
Practice Address - City:FOUNTAIN GREEN
Practice Address - State:UT
Practice Address - Zip Code:84632-7701
Practice Address - Country:US
Practice Address - Phone:801-903-5903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1235458555Medicaid