Provider Demographics
NPI:1851006936
Name:MARTIN, LISA RUNELL (MS, MAT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RUNELL
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 BLUEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-2207
Mailing Address - Country:US
Mailing Address - Phone:202-309-1411
Mailing Address - Fax:
Practice Address - Street 1:2923 BLUEBERRY LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-2207
Practice Address - Country:US
Practice Address - Phone:202-309-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician