Provider Demographics
NPI:1922515147
Name:MARRIOTT, JOHN BRIAN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRIAN
Last Name:MARRIOTT
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 1:5300 S 500 E STE 6
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6955
Mailing Address - Country:US
Mailing Address - Phone:801-392-0942
Mailing Address - Fax:
Practice Address - Street 1:2740 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3320
Practice Address - Country:US
Practice Address - Phone:801-675-5624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5219538-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT205509332OtherSUTTON CLINICAL SERVICES