Provider Demographics
NPI:1437130812
Name:MARTIN, JUDITH ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANN
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 1:2385 NW CABRILLO CT
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-6041
Mailing Address - Country:US
Mailing Address - Phone:541-957-9106
Mailing Address - Fax:541-957-9106
Practice Address - Street 1:2385 NW CABRILLO CT
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6041
Practice Address - Country:US
Practice Address - Phone:541-957-9106
Practice Address - Fax:541-957-9106
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR21648Medicare UPIN
OR100716Medicare ID - Type Unspecified