Provider Demographics
NPI:1033251376
Name:MARTIN MODEL, LCSW, PC
Entity Type:Organization
Organization Name:MARTIN MODEL, LCSW, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MODEL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:970-533-7816
Mailing Address - Street 1:40594 ROAD G
Mailing Address - Street 2:
Mailing Address - City:MANCOS
Mailing Address - State:CO
Mailing Address - Zip Code:81328-8927
Mailing Address - Country:US
Mailing Address - Phone:970-533-7816
Mailing Address - Fax:
Practice Address - Street 1:40594 ROAD G
Practice Address - Street 2:
Practice Address - City:MANCOS
Practice Address - State:CO
Practice Address - Zip Code:81328-8927
Practice Address - Country:US
Practice Address - Phone:970-533-7816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9830151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07983018Medicaid