MEDICARE: MS. MARTHA LARAINE MINER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	279317-6004	UT

General Provider Information

NPI Number	:	1871571638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARTHA LARAINE MINER LPC

Provider Business Mailing Address
First Line	:	5242 S 4820 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84118-6422
Country	:	US
Telephone Number	:	801-966-4251
Fax Number	:	801-966-4289

Provider Business Practice Location Address
First Line	:	5242 S 4820 W
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84118-6422
Country	:	US
Telephone Number	:	801-966-4251
Fax Number	:	801-966-4289

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	05/19/2008

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