Healthcare Provider Details

I. General information

NPI: 1861651325
Provider Name (Legal Business Name): DAVID LANCE MARTIN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N STATE ST
FAIRVIEW UT
84629-5554
US

IV. Provider business mailing address

152 NORTH 400 WEST
EPHRAIM UT
84627-2131
US

V. Phone/Fax

Practice location:
  • Phone: 435-610-1810
  • Fax:
Mailing address:
  • Phone: 435-283-8400
  • Fax: 435-283-8401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5001946-3502
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5001946-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: