Provider Demographics
NPI:1518476175
Name:MARTIN, ERICA LOLLER (LCSW-C)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:LOLLER
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:MISS
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:LOLLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:819 RITCHIE HWY STE 1020
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-4193
Mailing Address - Country:US
Mailing Address - Phone:410-431-5111
Mailing Address - Fax:
Practice Address - Street 1:819 RITCHIE HWY STE 1020
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-4193
Practice Address - Country:US
Practice Address - Phone:410-431-5111
Practice Address - Fax:410-431-5112
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD107951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD999005400Medicaid