Provider Demographics
NPI:1679781348
Name:MARTIN, LISAN
Entity Type:Individual
Prefix:
First Name:LISAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7707 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:CABIN JOHN
Mailing Address - State:MD
Mailing Address - Zip Code:20818-1702
Mailing Address - Country:US
Mailing Address - Phone:301-229-7839
Mailing Address - Fax:
Practice Address - Street 1:2607 CONNECTICUT AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-1522
Practice Address - Country:US
Practice Address - Phone:202-537-6614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC003025181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical