Provider Demographics
NPI:1376351049
Name:LIGHT, SHAUNA (ACHMC)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:LIGHT
Suffix:
Gender:F
Credentials:ACHMC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 W 1560 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2957
Mailing Address - Country:US
Mailing Address - Phone:801-787-2969
Mailing Address - Fax:
Practice Address - Street 1:1125 W CENTER ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-5207
Practice Address - Country:US
Practice Address - Phone:801-903-5903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13788659-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health