Provider Demographics
NPI:1053652495
Name:MARTIN, MARYEVA ELLA (LMSW)
Entity Type:Individual
Prefix:
First Name:MARYEVA
Middle Name:ELLA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MARYEVA
Other - Middle Name:ELLA
Other - Last Name:MERRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:3360 HIGHWAY 411 N
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:TN
Practice Address - Zip Code:37329-5276
Practice Address - Country:US
Practice Address - Phone:423-887-5131
Practice Address - Fax:423-887-5917
Is Sole Proprietor?:No
Enumeration Date:2013-03-11
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TN9715 (LMSW)104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker