Provider Demographics
NPI:1013205152
Name:WILTBANK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WILTBANK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1547
Mailing Address - Country:US
Mailing Address - Phone:801-375-4240
Mailing Address - Fax:801-375-4241
Practice Address - Street 1:525 W. 200 N.
Practice Address - Street 2:
Practice Address - City:MONA
Practice Address - State:UT
Practice Address - Zip Code:84648
Practice Address - Country:US
Practice Address - Phone:435-623-2825
Practice Address - Fax:435-623-2827
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor