Provider Demographics
NPI:1376037416
Name:MARTIN, MICHAEL TIMOTHY (LCSWA, CSAT-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TIMOTHY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSWA, CSAT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 WILLOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-6903
Mailing Address - Country:US
Mailing Address - Phone:919-776-6318
Mailing Address - Fax:
Practice Address - Street 1:1816 FRONT ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2582
Practice Address - Country:US
Practice Address - Phone:919-382-0288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0126031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical