MEDICARE: DR. MARK E OWENS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	112616-2501	UT

General Provider Information

NPI Number	:	1609966969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK E OWENS PH.D.

Provider Business Mailing Address
First Line	:	455 E 200 S STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2156
Country	:	US
Telephone Number	:	801-474-1900
Fax Number	:	801-532-1780

Provider Business Practice Location Address
First Line	:	455 E 200 S STE 110
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-2156
Country	:	US
Telephone Number	:	801-474-1900
Fax Number	:	801-532-1780

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	02/07/2011

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