Provider Demographics
NPI:1861651325
Name:MARTIN, DAVID LANCE (LCSW)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LANCE
Last Name:MARTIN
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 1:152 NORTH 400 WEST
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-2131
Mailing Address - Country:US
Mailing Address - Phone:435-283-8400
Mailing Address - Fax:435-283-8401
Practice Address - Street 1:125 N STATE ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:UT
Practice Address - Zip Code:84629-5554
Practice Address - Country:US
Practice Address - Phone:435-610-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5001946-35011041C0700X
UT5001946-3502101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health