Provider Demographics
NPI:1124335914
Name:CLARK, LOUISE
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E 4500 S STE 260
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3954
Mailing Address - Country:US
Mailing Address - Phone:801-747-3556
Mailing Address - Fax:801-747-2086
Practice Address - Street 1:345 E 4500 S STE 260
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3954
Practice Address - Country:US
Practice Address - Phone:801-747-3556
Practice Address - Fax:801-747-2086
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1497071419Medicaid