Provider Demographics
NPI:1053738567
Name:PUETT, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PUETT
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:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646-0461
Mailing Address - Country:US
Mailing Address - Phone:435-445-5200
Mailing Address - Fax:435-445-5201
Practice Address - Street 1:21360 NORTH 1450 EAST
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646-0461
Practice Address - Country:US
Practice Address - Phone:435-445-5200
Practice Address - Fax:435-445-5201
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT272503815Medicaid