Provider Demographics
NPI:1972531689
Name:MARTIN, ROBERTA
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:MARTIN-BURTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, ACSW, CAADC
Mailing Address - Street 1:42189 ANN ARBOR RD E
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4370
Mailing Address - Country:US
Mailing Address - Phone:734-453-5603
Mailing Address - Fax:734-453-5619
Practice Address - Street 1:42189 ANN ARBOR RD E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4370
Practice Address - Country:US
Practice Address - Phone:734-453-5603
Practice Address - Fax:734-453-5619
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801068960104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2689022Medicare ID - Type Unspecified