Provider Demographics
NPI:1225727795
Name:MARTIN, JUSTIN (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 WICKLOW ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-1407
Mailing Address - Country:US
Mailing Address - Phone:612-644-2980
Mailing Address - Fax:
Practice Address - Street 1:2924 WICKLOW ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55806-1407
Practice Address - Country:US
Practice Address - Phone:612-644-2980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN189901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical