Provider Demographics
NPI:1447444906
Name:CHAMBERLAIN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CHAMBERLAIN
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 1:1087 W 100 S
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5266
Mailing Address - Country:US
Mailing Address - Phone:435-725-6300
Mailing Address - Fax:435-725-6325
Practice Address - Street 1:285 W 800 S
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-3707
Practice Address - Country:US
Practice Address - Phone:435-725-6300
Practice Address - Fax:435-725-6325
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT317549-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist