Provider Demographics
NPI:1871222364
Name:MARTIN, MARY CHARLOTTE (LLMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHARLOTTE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4661
Mailing Address - Country:US
Mailing Address - Phone:906-225-1181
Mailing Address - Fax:
Practice Address - Street 1:200 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4661
Practice Address - Country:US
Practice Address - Phone:906-225-1181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851114893104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker