Provider Demographics
NPI:1881231421
Name:TALBOT, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:TALBOT
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 1:4626 N 300 W STE 150
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6077
Mailing Address - Country:US
Mailing Address - Phone:801-407-4134
Mailing Address - Fax:801-877-0864
Practice Address - Street 1:2989 W MAPLE LOOP DR STE 210
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-7413
Practice Address - Country:US
Practice Address - Phone:801-407-4134
Practice Address - Fax:801-877-0864
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10900317-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health