Provider Demographics
NPI:1942448741
Name:MARTIN, CYNTHIA (LICSW, CMHS)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LICSW, CMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13036 SE KENT KANGLEY RD STE 294
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13036 SE KENT KANGLEY RD STE 294
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7965
Practice Address - Country:US
Practice Address - Phone:253-655-9972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA172V00000X
WALW607133451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1942448741Medicaid