Provider Demographics
NPI:1588716039
Name:HALES, MARK T (LICSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:HALES
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:930 W HILL FIELD RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4687
Mailing Address - Country:US
Mailing Address - Phone:801-336-3040
Mailing Address - Fax:801-336-3041
Practice Address - Street 1:930 W HILL FIELD RD STE A
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4687
Practice Address - Country:US
Practice Address - Phone:801-336-3040
Practice Address - Fax:801-336-3041
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171331041C0700X
IA064551041C0700X
ND38461041C0700X
SD20381041C0700X
UT362016-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical