=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376611384
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK D CLAYTON LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 03/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 N 300 W STE 2
-----------------------------------------------------
City | SAINT GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84770-2770
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-673-4870
-----------------------------------------------------
Fax | 435-216-9403
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3219
-----------------------------------------------------
City | SAINT GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84771-3219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-673-4870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 881317683501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------