Provider Demographics
NPI:1619172806
Name:CLARK B. HOLLADAY, LCSW, LC
Entity Type:Organization
Organization Name:CLARK B. HOLLADAY, LCSW, LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:HOLLADAY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-623-5044
Mailing Address - Street 1:656 N MAIN ST
Mailing Address - Street 2:#5
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-1123
Mailing Address - Country:US
Mailing Address - Phone:435-623-5044
Mailing Address - Fax:435-623-5044
Practice Address - Street 1:656 N MAIN ST
Practice Address - Street 2:#5
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-1123
Practice Address - Country:US
Practice Address - Phone:435-623-5044
Practice Address - Fax:435-623-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT26555035011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty