Provider Demographics
NPI:1598907370
Name:MARTIN, WILLIAM BRUCE (LISW,LCSW)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BRUCE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LISW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8880 CYPRESS GATE DRIVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-6413
Mailing Address - Country:US
Mailing Address - Phone:937-903-6116
Mailing Address - Fax:
Practice Address - Street 1:8880 CYPRESS GATE DRIVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-6413
Practice Address - Country:US
Practice Address - Phone:937-903-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0010290104100000X
OHI.0010290SUPV1041C0700X
IN34005998A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker