Healthcare Provider Details

I. General information

NPI: 1912569021
Provider Name (Legal Business Name): CELESTIA LUELLA CLARK I MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 08/13/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 S 100 E STREET
ENTERPRISE UT
84725-7648
US

IV. Provider business mailing address

PO BOX 86
ENTERPRISE UT
84725-0086
US

V. Phone/Fax

Practice location:
  • Phone: 435-231-3657
  • Fax:
Mailing address:
  • Phone: 435-231-3657
  • Fax: 907-262-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10628149-3501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number159355
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: