Provider Demographics
NPI:1982231999
Name:OSBORNE, CHARLES MARK II
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARK
Last Name:OSBORNE
Suffix:II
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 1:951 E 1510 N
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-7706
Mailing Address - Country:US
Mailing Address - Phone:601-467-6856
Mailing Address - Fax:
Practice Address - Street 1:951 E 1510 N
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-7706
Practice Address - Country:US
Practice Address - Phone:601-467-6856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10738348-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1041C0700XOtherLICENSED CLINICAL SOCIAL WORKER