Provider Demographics
NPI:1821567736
Name:MARTIN, EDEN (LICSWA)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-5102
Mailing Address - Country:US
Mailing Address - Phone:616-464-6454
Mailing Address - Fax:206-652-1236
Practice Address - Street 1:216 JAMES ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-5102
Practice Address - Country:US
Practice Address - Phone:616-464-6454
Practice Address - Fax:206-652-1236
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60858331104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker