Basic Information
| Provider Information | |||||||||
| NPI: | 1235115932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUELLER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | NOLAND | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MUELLER | ||||||||
| OtherFirstName: | M | ||||||||
| OtherMiddleName: | NOLAND | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | VA SALT LAKE CITY HEALTH CARE SYS. MENTAL HEALTH ER | ||||||||
| Address2: | 500 FOOTHILL DR. | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | VA SALT LAKE CITY HEALTH CARE SYSTEM MENTAL | ||||||||
| Address2: | 500 FOOTHILL DR. | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015821565 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 03/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 99-3357453501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 107035233101 | 01 | UT | INTERMOUNTAIN HEALTH CARE | OTHER | 942938348MEU | 01 | UT | EDUCATORS MUTUAL | OTHER | 003103005 | 01 | UT | RAILROAD MEDICARE | OTHER | 33574535001001 | 01 | UT | BLUE CROSS | OTHER | 9429383484121A250 | 01 | UT | CHAMPUS | OTHER | 633730 | 01 | UT | DESERET MUTUAL | OTHER | P26861 | 01 | UT | MEDICARE ADVANTAGE PLUS | OTHER |