Provider Demographics
NPI:1639187461
Name:MARTIN, ELAINE LOUISE (LICSW)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:LOUISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RICHMOND SQ STE 232E
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5139
Mailing Address - Country:US
Mailing Address - Phone:401-354-9372
Mailing Address - Fax:401-633-6739
Practice Address - Street 1:1 RICHMOND SQ STE 232E
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-5139
Practice Address - Country:US
Practice Address - Phone:401-354-9372
Practice Address - Fax:401-633-6739
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW006381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7183-1OtherPSYCHOTHERAPIST
RI8090036381OtherMEDICARE PTAN
RI62-27220OtherPSYCHOTHERAPIST
RI411931OtherPSYCHOTHERAPIST