Basic Information
| Provider Information | |||||||||
| NPI: | 1487112264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 523 HERITAGE PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840415711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015259998 | ||||||||
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| Practice Location | |||||||||
| Address1: | 449 E 2100 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841152237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015962111 | ||||||||
| FaxNumber: | 8013593878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2019 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 8978900-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.