Provider Demographics
NPI:1861798142
Name:DE ST. AUBIN, MARK DAVID (LCSW, CT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:DE ST. AUBIN
Suffix:
Gender:M
Credentials:LCSW, CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3351 EL SERRITO DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4249
Mailing Address - Country:US
Mailing Address - Phone:801-891-3137
Mailing Address - Fax:
Practice Address - Street 1:5005 S 900 E STE 120
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-5711
Practice Address - Country:US
Practice Address - Phone:801-891-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133556-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical