Provider Demographics
NPI:1003088691
Name:SHRINKSTER, LLC
Entity type:Organization
Organization Name:SHRINKSTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:V
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-685-9600
Mailing Address - Street 1:860 E 4500 S STE 302
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3018
Mailing Address - Country:US
Mailing Address - Phone:801-685-9600
Mailing Address - Fax:801-268-3777
Practice Address - Street 1:860 E 4500 S STE 302
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-3018
Practice Address - Country:US
Practice Address - Phone:801-685-9600
Practice Address - Fax:801-268-3777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13472235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005737501Medicare PIN
UT005736601Medicare PIN
R61153Medicare UPIN