=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720906886
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA BREANN CLARK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2026
-----------------------------------------------------
Last Update Date | 07/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4933 S 1500 W STE 200
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84405-7738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-330-2818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 689 E 200 N
-----------------------------------------------------
City | BOUNTIFUL
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-3604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------