Healthcare Provider Details

I. General information

NPI: 1669948899
Provider Name (Legal Business Name): CHRISTOPHER CLARK HAWK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S 100 W
MOUNT PLEASANT UT
84647-1509
US

IV. Provider business mailing address

PO BOX 581074
SALT LAKE CITY UT
84158-1074
US

V. Phone/Fax

Practice location:
  • Phone: 435-659-9294
  • Fax:
Mailing address:
  • Phone: 435-659-9294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5331963-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: