Provider Demographics
NPI:1639412208
Name:SHELLY, MEGAN EIDENSHINK
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:EIDENSHINK
Last Name:SHELLY
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 1:2199 S 300 E
Mailing Address - Street 2:APT 2
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2873
Mailing Address - Country:US
Mailing Address - Phone:724-766-3227
Mailing Address - Fax:
Practice Address - Street 1:280 N MAIN ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6136
Practice Address - Country:US
Practice Address - Phone:801-292-8665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8611147-4201225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics