Provider Demographics
NPI:1235725789
Name:ELDRIDGE, MARTANA
Entity Type:Individual
Prefix:
First Name:MARTANA
Middle Name:
Last Name:ELDRIDGE
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 1:2694 N MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-6900
Mailing Address - Country:US
Mailing Address - Phone:716-771-9961
Mailing Address - Fax:
Practice Address - Street 1:2694 N MARTIN ST
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6900
Practice Address - Country:US
Practice Address - Phone:716-771-9961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0073221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical