Healthcare Provider Details

I. General information

NPI: 1811852619
Provider Name (Legal Business Name): GABRIEL CLARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6084 W 5200 S
HOOPER UT
84315-9561
US

IV. Provider business mailing address

6084 W 5200 S
HOOPER UT
84315-9561
US

V. Phone/Fax

Practice location:
  • Phone: 801-989-3222
  • Fax:
Mailing address:
  • Phone: 801-989-3222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14264714-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: