Provider Demographics
NPI:1861653784
Name:MOTTONEN, MARK DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:MOTTONEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 BISHOP FEDERAL LN
Mailing Address - Street 2:
Mailing Address - City:S SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2357
Mailing Address - Country:US
Mailing Address - Phone:801-487-7557
Mailing Address - Fax:801-468-6838
Practice Address - Street 1:451 BISHOP FEDERAL LN
Practice Address - Street 2:
Practice Address - City:S SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-2357
Practice Address - Country:US
Practice Address - Phone:801-487-7557
Practice Address - Fax:801-468-6838
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT139850-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005712211Medicare PIN