Provider Demographics
NPI:1992438048
Name:HARTMAN, MARK A (LSUDC, ACM, CPSS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HARTMAN
Suffix:
Gender:M
Credentials:LSUDC, ACM, CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 N 170 W
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3503
Mailing Address - Country:US
Mailing Address - Phone:801-648-5351
Mailing Address - Fax:
Practice Address - Street 1:60 S MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2136
Practice Address - Country:US
Practice Address - Phone:465-255-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1840175T00000X, 171M00000X
UT14185548-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator