Provider Demographics
NPI:1548993645
Name:CLARK, SKYLER ELDEN
Entity type:Individual
Prefix:
First Name:SKYLER
Middle Name:ELDEN
Last Name:CLARK
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 50207
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84605-0207
Mailing Address - Country:US
Mailing Address - Phone:801-407-4134
Mailing Address - Fax:801-866-0864
Practice Address - Street 1:774 S 1600 W STE 101
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:UT
Practice Address - Zip Code:84664-4346
Practice Address - Country:US
Practice Address - Phone:801-407-4134
Practice Address - Fax:801-877-0684
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13542811-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist