Provider Demographics
NPI:1609987957
Name:EYRE, SHELLY (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:EYRE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:EYRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 28128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-824-0722
Mailing Address - Fax:801-341-8218
Practice Address - Street 1:3051 W MAPLE LOOP DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5621
Practice Address - Country:US
Practice Address - Phone:801-824-0722
Practice Address - Fax:801-341-8218
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1393513501104100000X
UT139351-3501251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52896107802001OtherBCBS OF UTAH
UT814241OtherDMBA
UT87925OtherPEHP