Provider Demographics
NPI:1659703213
Name:MARTIN, SAMANTHA (LICSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
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 1:1443 BEACON ST
Mailing Address - Street 2:#401
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-9714
Mailing Address - Country:US
Mailing Address - Phone:617-731-3200
Mailing Address - Fax:
Practice Address - Street 1:227 BABCOCK ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-6773
Practice Address - Country:US
Practice Address - Phone:617-731-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219083104100000X
MA1191991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker