Basic Information
| Provider Information | |||||||||
| NPI: | 1588140115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARK | ||||||||
| FirstName: | DRESDEN | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LSUDC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 344 E 100 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841111700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014284257 | ||||||||
| FaxNumber: | 8013361787 | ||||||||
| Practice Location | |||||||||
| Address1: | 344 E 100 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841111700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014284257 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2018 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11330795-6005 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.