Basic Information
| Provider Information | |||||||||
| NPI: | 1104274448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTINEZ | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2621 S 3270 W | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841191119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3852612614 | ||||||||
| FaxNumber: | 8774974661 | ||||||||
| Practice Location | |||||||||
| Address1: | 4745 S 3200 W STE A | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841292822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0196462148 | ||||||||
| FaxNumber: | 8774974661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 9809996-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.