Provider Demographics
NPI:1821007154
Name:MARTIN, SUSAN M (LISW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3242
Mailing Address - Country:US
Mailing Address - Phone:641-472-1684
Mailing Address - Fax:641-472-4609
Practice Address - Street 1:602 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1924
Practice Address - Country:US
Practice Address - Phone:515-283-1230
Practice Address - Fax:515-283-2256
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA038161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA465309OtherVALUE OPTIONS RAILROAD
IA231967OtherMIDLANDS
IA33170OtherWELLMARK
IA0224949Medicaid
IAI0956Medicare ID - Type UnspecifiedMEDICARE