Provider Demographics
NPI:1487973863
Name:PITCHER, SHANE MAYLIN (LCSW)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:MAYLIN
Last Name:PITCHER
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 1:5626 VISTA RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-9354
Mailing Address - Country:US
Mailing Address - Phone:801-894-8548
Mailing Address - Fax:
Practice Address - Street 1:645 S 1300 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-3206
Practice Address - Country:US
Practice Address - Phone:385-227-8565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7036797-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7036797-3502OtherDOPL LISCENCE
UT7036797-3501OtherDOPL LISCENCE LCSW