Provider Demographics
NPI:1255681276
Name:MARTIN, TIA ELISE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TIA
Middle Name:ELISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 WHISPERING PINES TRL SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35603-3201
Mailing Address - Country:US
Mailing Address - Phone:256-552-7540
Mailing Address - Fax:
Practice Address - Street 1:911 WHISPERING PINES TRL SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-3201
Practice Address - Country:US
Practice Address - Phone:256-552-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040037171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical