Provider Demographics
NPI:1184926214
Name:LONG, SHANEL ROSE (LSAC)
Entity type:Individual
Prefix:MRS
First Name:SHANEL
Middle Name:ROSE
Last Name:LONG
Suffix:
Gender:F
Credentials:LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 N LOAFER CANYON RD
Mailing Address - Street 2:
Mailing Address - City:ELK RIDGE
Mailing Address - State:UT
Mailing Address - Zip Code:84651-8572
Mailing Address - Country:US
Mailing Address - Phone:801-885-7372
Mailing Address - Fax:
Practice Address - Street 1:151 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-4427
Practice Address - Country:US
Practice Address - Phone:801-851-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6500376-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)