Healthcare Provider Details

I. General information

NPI: 1972963387
Provider Name (Legal Business Name): MAYRA MARTINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 S WASHINGTON ST APT 203
SALT LAKE CITY UT
84101-3017
US

IV. Provider business mailing address

938 S WASHINGTON ST APT 203
SALT LAKE CITY UT
84101-3017
US

V. Phone/Fax

Practice location:
  • Phone: 925-338-4764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number103085222506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: