MEDICARE: SUSIE LEE MARTIN LCSW

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	1041C0700X	Clinical Social Worker	12476698-3501	UT

General Provider Information

NPI Number	:	1902615719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSIE LEE MARTIN LCSW

Provider Business Mailing Address
First Line	:	PO BOX 360005
Second Line	:
City	:	MONUMENT VALLEY
State	:	UT
Zip	:	84536-0005
Country	:	US
Telephone Number	:	435-727-3000
Fax Number	:	435-727-3001

Provider Business Practice Location Address
First Line	:	30 W MEDICAL DR
Second Line	:
City	:	MONUMENT VALLEY
State	:	UT
Zip	:	84536-7705
Country	:	US
Telephone Number	:	435-727-3000
Fax Number	:	435-727-3001

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

Provider Enumeration Date	:	01/06/2025
Last Update Date	:	01/06/2025

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