Provider Demographics
NPI:1740503150
Name:STOWELL, SHANE D (PSYD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:D
Last Name:STOWELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 E 930 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5001
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:801-225-1525
Practice Address - Street 1:412 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3728
Practice Address - Country:US
Practice Address - Phone:801-235-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7369628-2501-2501103T00000X
UT7369628-2501103TA0400X, 103TC0700X, 103TC1900X
UT2369628-2501103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service