MEDICARE: MR. MARTIN THOMAS O DONNELL JR. 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	106H00000X	Marriage & Family Therapist	1014263902	UT

General Provider Information

NPI Number	:	1982774832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN THOMAS O DONNELL JR. LCSW

Provider Business Mailing Address
First Line	:	132 SOUTH STATE STREET
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1506
Country	:	US
Telephone Number	:	801-240-6500
Fax Number	:	801-240-5508

Provider Business Practice Location Address
First Line	:	132 SOUTH STATE STREET
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1506
Country	:	US
Telephone Number	:	801-240-6500
Fax Number	:	801-240-5508

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/08/2007

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