Provider Demographics
NPI:1841752490
Name:MARTIN, LIZATTE
Entity Type:Individual
Prefix:
First Name:LIZATTE
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 1:1228 GARRET AVE
Mailing Address - Street 2:
Mailing Address - City:CHURCHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20733-9520
Mailing Address - Country:US
Mailing Address - Phone:667-200-6006
Mailing Address - Fax:
Practice Address - Street 1:1228 GARRET AVE
Practice Address - Street 2:
Practice Address - City:CHURCHTON
Practice Address - State:MD
Practice Address - Zip Code:20733-9520
Practice Address - Country:US
Practice Address - Phone:667-200-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No251B00000XAgenciesCase Management