Provider Demographics
NPI:1780224709
Name:MARTINEZ, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 N 2000 W STE 6
Mailing Address - Street 2:
Mailing Address - City:FARR WEST
Mailing Address - State:UT
Mailing Address - Zip Code:84404-8060
Mailing Address - Country:US
Mailing Address - Phone:801-605-3086
Mailing Address - Fax:
Practice Address - Street 1:1812 N 2000 W STE 6
Practice Address - Street 2:
Practice Address - City:FARR WEST
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-605-3086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty