Provider Demographics
NPI:1033579099
Name:MARTIN, BENJAMIN SR
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MARTIN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N HOWARD AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422-1256
Mailing Address - Country:US
Mailing Address - Phone:810-878-5050
Mailing Address - Fax:
Practice Address - Street 1:112 N HOWARD AVE
Practice Address - Street 2:
Practice Address - City:CROSWELL
Practice Address - State:MI
Practice Address - Zip Code:48422-1278
Practice Address - Country:US
Practice Address - Phone:810-878-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011007301041C0700X
MI68011080501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical