Provider Demographics
NPI:1548841240
Name:SHOAF, BREANNA PAIGE
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:PAIGE
Last Name:SHOAF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 N 300 E APT 203
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-7402
Mailing Address - Country:US
Mailing Address - Phone:317-966-1265
Mailing Address - Fax:
Practice Address - Street 1:1140 W 1130 S SUITE B
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician