Provider Demographics
NPI:1487639852
Name:MARTIN, ETTA LOUISE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ETTA
Middle Name:LOUISE
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 1:4201 VENTURA CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4329
Mailing Address - Country:US
Mailing Address - Phone:818-789-8784
Mailing Address - Fax:818-905-2845
Practice Address - Street 1:4911 VAN NUYS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1716
Practice Address - Country:US
Practice Address - Phone:818-817-3248
Practice Address - Fax:818-905-2845
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS215261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical