Provider Demographics
NPI:1033178314
Name:MARTIN, ERNESTINA M (LCSW)
Entity Type:Individual
Prefix:
First Name:ERNESTINA
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E 4500 S
Mailing Address - Street 2:SUITE C150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4533
Mailing Address - Country:US
Mailing Address - Phone:801-288-0747
Mailing Address - Fax:
Practice Address - Street 1:243 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2515
Practice Address - Country:US
Practice Address - Phone:801-582-7708
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8312610335011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87045764600001OtherBCBS ID NUMBER