Provider Demographics
NPI:1811028962
Name:MANAZER, MARK STEPHEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:MANAZER
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 1:5643 BONICA LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84065-1741
Mailing Address - Country:US
Mailing Address - Phone:801-446-4964
Mailing Address - Fax:
Practice Address - Street 1:511 W 200 S
Practice Address - Street 2:SUITE 160
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1185
Practice Address - Country:US
Practice Address - Phone:801-363-9414
Practice Address - Fax:801-355-3546
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT380579-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist