Provider Demographics
NPI:1659318848
Name:MARTIN, CREWSON ANDREW (MSW, L-CSW)
Entity Type:Individual
Prefix:
First Name:CREWSON
Middle Name:ANDREW
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MSW, L-CSW
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:RICHARD
Other - Last Name:LAUTERBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, L-CSW
Mailing Address - Street 1:210 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2010
Mailing Address - Country:US
Mailing Address - Phone:631-880-2531
Mailing Address - Fax:631-476-1835
Practice Address - Street 1:210 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2010
Practice Address - Country:US
Practice Address - Phone:631-880-2531
Practice Address - Fax:631-476-1835
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR038729-1103T00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist