Provider Demographics
NPI:1053496406
Name:MARTIN, BRENDA K (LCSW MSW)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:K
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 N GREEN ST
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-5375
Mailing Address - Country:US
Mailing Address - Phone:704-873-7816
Mailing Address - Fax:704-873-7817
Practice Address - Street 1:127 N GREEN ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5375
Practice Address - Country:US
Practice Address - Phone:704-873-7816
Practice Address - Fax:704-873-7817
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0006131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00426430OtherRAILROAD MEDICARE
NC1010XOtherBCBS
1010XOtherBCBS
NC6002130Medicaid
NC1010XOtherBCBS