Healthcare Provider Details

I. General information

NPI: 1174310494
Provider Name (Legal Business Name): MARIANO OTTONE MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL BLVD
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

1127 W STONEHAVEN DR
NORTH SALT LAKE UT
84054-5033
US

V. Phone/Fax

Practice location:
  • Phone: 831-594-3091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number14240815-25001
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: