MEDICARE: DR. MARTINA RICH PHD

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	369755-2501	UT

General Provider Information

NPI Number	:	1053452672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTINA RICH PHD

Provider Business Mailing Address
First Line	:	1371 LINCOLN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2315
Country	:	US
Telephone Number	:	801-581-6228
Fax Number	:	801-585-6702

Provider Business Practice Location Address
First Line	:	30 N 1900 E
Second Line	:	1R52 SOM
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-2119
Country	:	US
Telephone Number	:	801-581-6228
Fax Number	:	801-585-6702

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	07/08/2007

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