Provider Demographics
NPI:1194470880
Name:MARTINEZ, SHANNON (RBT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 S HIGHLAND DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84106-6004
Mailing Address - Country:US
Mailing Address - Phone:801-647-3920
Mailing Address - Fax:801-931-2607
Practice Address - Street 1:3006 S HIGHLAND DR STE 210
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84106-6004
Practice Address - Country:US
Practice Address - Phone:801-647-3920
Practice Address - Fax:801-931-2607
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT21183191106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician