Provider Demographics
NPI:1982774832
Name:O DONNELL, MARTIN THOMAS JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:THOMAS
Last Name:O DONNELL
Suffix:JR
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 1:132 SOUTH STATE STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1506
Mailing Address - Country:US
Mailing Address - Phone:801-240-6500
Mailing Address - Fax:801-240-5508
Practice Address - Street 1:132 SOUTH STATE STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1506
Practice Address - Country:US
Practice Address - Phone:801-240-6500
Practice Address - Fax:801-240-5508
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1014263902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000007635Medicare ID - Type Unspecified