Provider Demographics
NPI:1578629812
Name:MARTIN, JOHN B (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
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 1:5207 TROUBLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-4915
Mailing Address - Country:US
Mailing Address - Phone:727-847-0069
Mailing Address - Fax:727-849-3890
Practice Address - Street 1:5207 TROUBLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4915
Practice Address - Country:US
Practice Address - Phone:727-847-0069
Practice Address - Fax:727-849-3890
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 7491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ08142Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER