Provider Demographics
NPI:1891460341
Name:SHAW, MARANDA
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:
Last Name:SHAW
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 1:190 W 100 S STE A
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-2531
Mailing Address - Country:US
Mailing Address - Phone:435-896-6440
Mailing Address - Fax:
Practice Address - Street 1:190 W 100 S STE A
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2531
Practice Address - Country:US
Practice Address - Phone:435-896-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health