Provider Demographics
NPI:1457674368
Name:MARTIN, CHARLES HAROLD (LCSW-BACS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HAROLD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW-BACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4739 HWY 10
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:LA
Mailing Address - Zip Code:70748
Mailing Address - Country:US
Mailing Address - Phone:225-634-0094
Mailing Address - Fax:225-634-0094
Practice Address - Street 1:4739 HWY 10
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748
Practice Address - Country:US
Practice Address - Phone:225-634-0094
Practice Address - Fax:225-634-0094
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical