Provider Demographics
NPI:1922015536
Name:NELSON, MARTINA JANE (LCSW, LAC,CMHP)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:JANE
Last Name:NELSON
Suffix:
Gender:F
Credentials:LCSW, LAC,CMHP
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:JANE
Other - Last Name:BOOTHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC, LAC
Mailing Address - Street 1:603 CALIFORNIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923
Mailing Address - Country:US
Mailing Address - Phone:406-293-7116
Mailing Address - Fax:406-293-8119
Practice Address - Street 1:603 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-1901
Practice Address - Country:US
Practice Address - Phone:406-293-7116
Practice Address - Fax:406-293-8119
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT954101YA0400X
MT7991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0044707Medicaid