Provider Demographics
NPI:1982179727
Name:RAINSDON, MARK ANDREW (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:RAINSDON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3948 S 2075 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-3508
Mailing Address - Country:US
Mailing Address - Phone:208-681-0558
Mailing Address - Fax:
Practice Address - Street 1:9091 E 100 S
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84317-9608
Practice Address - Country:US
Practice Address - Phone:801-334-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9431148-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical