Provider Demographics
NPI:1487112264
Name:MARTIN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 HERITAGE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5711
Mailing Address - Country:US
Mailing Address - Phone:801-525-9998
Mailing Address - Fax:
Practice Address - Street 1:449 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2237
Practice Address - Country:US
Practice Address - Phone:801-596-2111
Practice Address - Fax:801-359-3878
Is Sole Proprietor?:No
Enumeration Date:2019-03-11
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8978900-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical