Provider Demographics
NPI:1326102310
Name:MEDINA MARTINEZ, C KAI (LCSW)
Entity type:Individual
Prefix:
First Name:C KAI
Middle Name:
Last Name:MEDINA MARTINEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 S MAIN ST # 2A
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-2668
Mailing Address - Country:US
Mailing Address - Phone:801-556-7762
Mailing Address - Fax:
Practice Address - Street 1:33 S MAIN ST # 2A
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-2668
Practice Address - Country:US
Practice Address - Phone:801-467-2072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT310922-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical