Provider Demographics
NPI:1023069358
Name:GLADE, MARK HAMILTON (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:HAMILTON
Last Name:GLADE
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 1:2351 CAVE HOLLOW WAY
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1203
Mailing Address - Country:US
Mailing Address - Phone:801-294-3704
Mailing Address - Fax:
Practice Address - Street 1:625 E 8400 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-0525
Practice Address - Country:US
Practice Address - Phone:801-566-2556
Practice Address - Fax:801-566-3926
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT312261-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical