Provider Demographics
NPI:1053993501
Name:WEAVER, SHANNON (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WEAVER
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 1:882 S 550 E
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-4547
Mailing Address - Country:US
Mailing Address - Phone:801-631-7476
Mailing Address - Fax:
Practice Address - Street 1:3100 PINEBROOK RD STE 1250B
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5663
Practice Address - Country:US
Practice Address - Phone:801-631-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5121600-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health