Provider Demographics
NPI:1609966969
Name:OWENS, MARK E (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:OWENS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 E 200 S STE 110
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2156
Mailing Address - Country:US
Mailing Address - Phone:801-474-1900
Mailing Address - Fax:801-532-1780
Practice Address - Street 1:455 E 200 S STE 110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2156
Practice Address - Country:US
Practice Address - Phone:801-474-1900
Practice Address - Fax:801-532-1780
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT112616-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000000123Medicare ID - Type Unspecified