Provider Demographics
NPI:1770554289
Name:SHELTON, MARK JIM (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:JIM
Last Name:SHELTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 CHAMPLAINE ST.
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-882-8552
Mailing Address - Fax:
Practice Address - Street 1:100 S 1000 W
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-4010
Practice Address - Country:US
Practice Address - Phone:435-843-3520
Practice Address - Fax:435-843-3555
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT128877-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942938348006OtherCHAMPUS
UTR95603OtherICAR
UT107000925101OtherINTERMOUNTAIN HEALTH CARE
UT942938348SH1OtherEDUCATOR'S MUTUAL
UT292738OtherDESERET MUTUAL
UTR95603Medicare UPIN