Provider Demographics
NPI:1114632262
Name:MARTIN, MAKAYLA
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 SANDSTONE CT APT 308
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23608-2319
Mailing Address - Country:US
Mailing Address - Phone:706-284-5327
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14354104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker