Provider Demographics
NPI:1447784251
Name:MARTIN, MOLLY (LISW-S)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 BRIDGE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3086
Mailing Address - Country:US
Mailing Address - Phone:216-282-3838
Mailing Address - Fax:
Practice Address - Street 1:3000 BRIDGE AVE STE 4
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3086
Practice Address - Country:US
Practice Address - Phone:216-282-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0700171-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0218401Medicaid