Provider Demographics
NPI:1164492583
Name:MARTINEZ, KENNETH J (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 S MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-3176
Mailing Address - Country:US
Mailing Address - Phone:801-539-7035
Mailing Address - Fax:
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3176
Practice Address - Country:US
Practice Address - Phone:801-539-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14064135011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942938348MA2OtherEDUCATORS MUTUAL
UTR79728OtherMEDICARE ADVANTAGE PLANS
UT107001385101OtherINTRMTN HEALTH CARE
UT261919OtherDESERET MUTUAL
UT942938348OtherCHAMPUS
UTXOtherBLUE CROSS
UT003104013OtherRAILROAD MEDICARE
UT003104013OtherRAILROAD MEDICARE
UT004662037Medicare PIN
UTR79728OtherMEDICARE ADVANTAGE PLANS
UT942938348MA2OtherEDUCATORS MUTUAL