Provider Demographics
NPI:1073008520
Name:LIGHT, MARCIA R
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:R
Last Name:LIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1578 W 1700 S STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-3461
Mailing Address - Country:US
Mailing Address - Phone:801-972-2710
Mailing Address - Fax:
Practice Address - Street 1:397 S 1125 W
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5230
Practice Address - Country:US
Practice Address - Phone:801-663-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1073008520OtherBCBS, U OF U, EMI