Provider Demographics
NPI:1700255031
Name:OTANEZ, SHANNALEE (LCSW)
Entity Type:Individual
Prefix:
First Name:SHANNALEE
Middle Name:
Last Name:OTANEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 W PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4355
Mailing Address - Country:US
Mailing Address - Phone:801-554-0663
Mailing Address - Fax:
Practice Address - Street 1:124 S 400 E STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-5315
Practice Address - Country:US
Practice Address - Phone:435-774-0485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10347309-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical