Provider Demographics
NPI:1629068622
Name:MARTELLO, MARK ALLEN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:MARTELLO
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:N10994 SPRING CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-9718
Mailing Address - Country:US
Mailing Address - Phone:808-754-5504
Mailing Address - Fax:
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:906-774-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8830-1231041C0700X
IDLCSW-12051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW-1205OtherSTATE LICENSE