Healthcare Provider Details

I. General information

NPI: 1437476959
Provider Name (Legal Business Name): MARK STEVEN TILLER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2887 MELBOURNE ST
SALT LAKE CITY UT
84106-4071
US

IV. Provider business mailing address

2887 MELBOURNE ST
SALT LAKE CITY UT
84106-4071
US

V. Phone/Fax

Practice location:
  • Phone: 801-485-2538
  • Fax:
Mailing address:
  • Phone: 801-485-2538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number137552-3501
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: