Provider Demographics
NPI:1578614335
Name:MARTIN, TERRY J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-1001 HOOMUA ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-4260
Mailing Address - Country:US
Mailing Address - Phone:808-271-5112
Mailing Address - Fax:
Practice Address - Street 1:98-211 PALI MOMI ST STE 707
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4339
Practice Address - Country:US
Practice Address - Phone:808-271-5112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI30741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI101448Medicare ID - Type Unspecified