Provider Demographics
NPI:1467745893
Name:DEVOE, MARK D (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:DEVOE
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 1:4007 IVY AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GREEN
Mailing Address - State:UT
Mailing Address - Zip Code:84050
Mailing Address - Country:US
Mailing Address - Phone:801-821-0663
Mailing Address - Fax:
Practice Address - Street 1:982 CHAMBERS ST
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4571
Practice Address - Country:US
Practice Address - Phone:801-479-4105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8331538-35011041C0700X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid
UT000055266Medicare PIN