1619242062 NPI number — MR. MARTIN LYNN MACDONALD LPC

Table of content: MR. MARTIN LYNN MACDONALD LPC (NPI 1619242062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619242062 NPI number — MR. MARTIN LYNN MACDONALD LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACDONALD
Provider First Name:
MARTIN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619242062
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2536 ECCLES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OGDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84401-2718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-866-9036
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2872 S. HIGHLAND DRIVE
Provider Second Line Business Practice Location Address:
TOUCHSTONE THERAPY CENTER
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-485-8051
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  8060867-6009 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)