Provider Demographics
NPI:1649419342
Name:WAYNE A MARTIN LCSW LLC
Entity Type:Organization
Organization Name:WAYNE A MARTIN LCSW LLC
Other - Org Name:WAYNE A MARTIN, LCSW, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-873-1958
Mailing Address - Street 1:708 MOBJACK PL
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1957
Mailing Address - Country:US
Mailing Address - Phone:757-873-1958
Mailing Address - Fax:757-873-2143
Practice Address - Street 1:708 MOBJACK PL
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-1957
Practice Address - Country:US
Practice Address - Phone:757-873-1958
Practice Address - Fax:757-873-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040001581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty