Provider Demographics
NPI:1346490695
Name:MARTIN, MARK (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5673 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-1119
Mailing Address - Country:US
Mailing Address - Phone:540-523-8080
Mailing Address - Fax:540-512-9775
Practice Address - Street 1:5673 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1119
Practice Address - Country:US
Practice Address - Phone:540-523-8080
Practice Address - Fax:540-512-9775
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904007708101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health