Provider Demographics
NPI:1629157623
Name:CHAMBLIN, MARTHA MUIR (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:MUIR
Last Name:CHAMBLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARCY
Other - Middle Name:
Other - Last Name:BORNICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:478 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-787-2207
Mailing Address - Fax:203-773-3626
Practice Address - Street 1:478 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-787-2207
Practice Address - Fax:203-773-3626
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0053681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical