Provider Demographics
NPI:1215984927
Name:FALLIS, MARTHA BURKETT (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:BURKETT
Last Name:FALLIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:BURKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4334 TIDWELL ST
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-5231
Mailing Address - Country:US
Mailing Address - Phone:801-244-2426
Mailing Address - Fax:
Practice Address - Street 1:4334 TIDWELL ST
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-5231
Practice Address - Country:US
Practice Address - Phone:801-244-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56599619-3502104100000X
UT5659619-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker