Provider Demographics
NPI:1366816902
Name:SHELLEY, MACKAY DALE
Entity Type:Individual
Prefix:MR
First Name:MACKAY
Middle Name:DALE
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0028
Mailing Address - Country:US
Mailing Address - Phone:435-436-5321
Mailing Address - Fax:435-436-5322
Practice Address - Street 1:4800 EAST 17160 NORTH
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0028
Practice Address - Country:US
Practice Address - Phone:435-436-5321
Practice Address - Fax:435-436-5322
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor