Provider Demographics
NPI:1104274448
Name:MARTINEZ, MAYRA (LCSW)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 S 3270 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1119
Mailing Address - Country:US
Mailing Address - Phone:385-261-2614
Mailing Address - Fax:877-497-4661
Practice Address - Street 1:4745 S 3200 W STE A
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-2822
Practice Address - Country:US
Practice Address - Phone:019-646-2148
Practice Address - Fax:877-497-4661
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
UT9809996-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker