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Provider Information for 1770502379

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know

MARK D. WORTHEN PSY.D.

Gender: MALE

Individual NPI: 1770502379

Calendar   Last Updated:  2019-10-12
  Certification Date: 

Details

Name Value
NPI 1770502379
Enumeration Date 2006-07-18
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address PO BOX 980130
PARK CITY, UT 84098-0130
United States

Phone: 828-279-4486 | Fax:
View Map External Link
Primary Practice Address 1182 CENTER DR STE D160
PARK CITY, UT 84098-1287
United States

Phone: 435-602-1288 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
MEDICAID NC 6000718
Taxonomy
Primary Taxonomy Selected Taxonomy State License Number
Yes 103TC0700X - Psychologist Clinical NC 1835
No 103TA0400X - Psychologist Addiction (Substance Use Disorder) NC 1835
No 103TF0200X - Psychologist Forensic UT 10951856-2501
No 103TP2701X - Psychologist Group Psychotherapy UT 10951856-2501