Provider Demographics
NPI:1851497580
Name:MACKAY-CLARK, DEANNA (OTR)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:MACKAY-CLARK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:DEANNA
Other - Last Name:MACKAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:9301 SOUTH WIGHTS FORT RD
Practice Address - Street 2:SUITE 215
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:801-282-2200
Practice Address - Fax:801-282-2220
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1088554201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTL0295Medicaid