Healthcare Provider Details

I. General information

NPI: 1619172806
Provider Name (Legal Business Name): CLARK B. HOLLADAY, LCSW, LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 N MAIN ST #5
NEPHI UT
84648-1123
US

IV. Provider business mailing address

656 N MAIN ST #5
NEPHI UT
84648-1123
US

V. Phone/Fax

Practice location:
  • Phone: 435-623-5044
  • Fax: 435-623-5044
Mailing address:
  • Phone: 435-623-5044
  • Fax: 435-623-5044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2655503501
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. CLARK B. HOLLADAY
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 435-623-5044