Provider Demographics
NPI:1104846294
Name:MARTIN, MICHAEL W (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 TILGHMAN DR
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-5533
Mailing Address - Country:US
Mailing Address - Phone:910-892-1333
Mailing Address - Fax:910-892-2929
Practice Address - Street 1:104 TILGHMAN DR
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5533
Practice Address - Country:US
Practice Address - Phone:910-892-1333
Practice Address - Fax:910-892-2929
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0015271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003580Medicaid