Provider Demographics
NPI:1417252297
Name:KILGORE, SHELLEY ALISKA
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:ALISKA
Last Name:KILGORE
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 1:3944 S 400 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1600
Mailing Address - Country:US
Mailing Address - Phone:801-261-1442
Mailing Address - Fax:
Practice Address - Street 1:3944 S 400 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1600
Practice Address - Country:US
Practice Address - Phone:801-261-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT77427673502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker