Healthcare Provider Details

I. General information

NPI: 1467745893
Provider Name (Legal Business Name): MARK D DEVOE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 CHAMBERS ST
SOUTH OGDEN UT
84403-4571
US

IV. Provider business mailing address

4007 IVY AVENUE
MOUNTAIN GREEN UT
84050
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-4105
  • Fax:
Mailing address:
  • Phone: 801-821-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8331538-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: