Provider Demographics
NPI:1487616330
Name:WEISBENDER, MARK ALAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:WEISBENDER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 824
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-0801
Mailing Address - Country:US
Mailing Address - Phone:801-983-5540
Mailing Address - Fax:801-983-5542
Practice Address - Street 1:3195 S MAIN ST STE 180
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3790
Practice Address - Country:US
Practice Address - Phone:801-983-5540
Practice Address - Fax:801-983-5542
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT263270-35011041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788802Medicaid