Provider Demographics
NPI:1518401504
Name:MARTIN, ROBERT (LCSW CSAC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 RADFORD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-3512
Mailing Address - Country:US
Mailing Address - Phone:804-354-1996
Mailing Address - Fax:804-354-5516
Practice Address - Street 1:4906 RADFORD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-3512
Practice Address - Country:US
Practice Address - Phone:804-354-1996
Practice Address - Fax:804-354-5516
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710000721101YA0400X
VA09040027651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA13939610OtherCAQH