Provider Demographics
NPI:1508352568
Name:EARLY, MARTHA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:ANN
Last Name:EARLY
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 1:2705 E BURNSIDE ST STE 206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1768
Mailing Address - Country:US
Mailing Address - Phone:503-539-7799
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST STE 206
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1768
Practice Address - Country:US
Practice Address - Phone:503-539-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102203104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker