Healthcare Provider Details

I. General information

NPI: 1487785028
Provider Name (Legal Business Name): MARK S. SMASAL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N PINION HILLS DR
DAMMERON VALLEY UT
84783-5180
US

IV. Provider business mailing address

PO BOX 1430
ST GEORGE UT
84771-1430
US

V. Phone/Fax

Practice location:
  • Phone: 702-994-3890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0364
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number277642-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: