Healthcare Provider Details

I. General information

NPI: 1467034454
Provider Name (Legal Business Name): BRIAN JOSEPH MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 W 2700 S
SOUTH SALT LAKE UT
84115-2904
US

IV. Provider business mailing address

331 W 2700 S
SOUTH SALT LAKE UT
84115-2904
US

V. Phone/Fax

Practice location:
  • Phone: 801-678-3317
  • Fax:
Mailing address:
  • Phone: 801-678-3317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13998800-3502
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: