Provider Demographics
NPI:1447605282
Name:BURTON, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BURTON
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 1:515 S 700 E STE 2A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2855
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:801-935-4946
Practice Address - Street 1:515 S 700 E STE 2A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2855
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10784066-2506103K00000X
106E00000X
UT1-19-39755103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1-19-39755OtherBACB
UT10784066-2506OtherDOPL