Provider Demographics
NPI:1891807376
Name:MARTIN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
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 1:1521 CONCORD PIKE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3642
Mailing Address - Country:US
Mailing Address - Phone:302-893-3717
Mailing Address - Fax:302-416-5735
Practice Address - Street 1:1601 CONCORD PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3612
Practice Address - Country:US
Practice Address - Phone:302-893-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001785103TC0700X
DCPSY1628103TC0700X
DEB1-0000699103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
111917629OtherUNITED BEHAVIORAL HEALTH
21385OtherCOMPSYCH
2270828OtherCIGNA
DE510387PSYOtherBLUE CROSS BLUE SHIELD
7391402OtherAETNA
111917629OtherUNITED HEALTH CARE