Provider Demographics
NPI:1114263647
Name:MARTIN, MEGAN MARIE (MS, LCGC)
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 S WAKARA WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1242
Mailing Address - Country:US
Mailing Address - Phone:801-931-6203
Mailing Address - Fax:801-931-6201
Practice Address - Street 1:423 S WAKARA WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1242
Practice Address - Country:US
Practice Address - Phone:801-931-6203
Practice Address - Fax:801-931-6201
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8045782-3601170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS