Provider Demographics
NPI:1669685145
Name:MARTIN, CARLA LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 FORGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001
Mailing Address - Country:US
Mailing Address - Phone:860-404-8846
Mailing Address - Fax:
Practice Address - Street 1:146 ELM ST STE A-12
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2808
Practice Address - Country:US
Practice Address - Phone:203-439-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0056351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004068284Medicaid
CT004215308Medicaid
CT008030935Medicaid