Provider Demographics
NPI:1386912871
Name:WARD, MARK WILSON (LMFT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILSON
Last Name:WARD
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E SPRING DR.
Mailing Address - Street 2:
Mailing Address - City:TOQUERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84774
Mailing Address - Country:US
Mailing Address - Phone:435-635-0300
Mailing Address - Fax:
Practice Address - Street 1:730 E SPRING DR.
Practice Address - Street 2:
Practice Address - City:TOQUERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84774
Practice Address - Country:US
Practice Address - Phone:435-635-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
UT8148314-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190077AHNMedicaid