Provider Demographics
NPI:1306407069
Name:MARTIN, ALICIA ANNE (LMSW)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANNE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15773 KITCHEL LN
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2928
Mailing Address - Country:US
Mailing Address - Phone:616-634-9963
Mailing Address - Fax:
Practice Address - Street 1:1611 OAK AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-2468
Practice Address - Country:US
Practice Address - Phone:231-767-1921
Practice Address - Fax:231-767-0527
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MI68011150211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical