Provider Demographics
NPI:1417002197
Name:MARTIN, LISA R (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:R
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 1:455 INDIAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2833
Mailing Address - Country:US
Mailing Address - Phone:321-784-3532
Mailing Address - Fax:
Practice Address - Street 1:1370 PATRICK DR
Practice Address - Street 2:
Practice Address - City:PATRICK AFB
Practice Address - State:FL
Practice Address - Zip Code:32925-3606
Practice Address - Country:US
Practice Address - Phone:321-494-8234
Practice Address - Fax:321-494-8074
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW29791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVAD000Medicare UPIN