Provider Demographics
NPI:1134168602
Name:MARTIN, AMY ELIZABETH (LCSW)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:SANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2702 E NORTHGATE ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2856
Mailing Address - Country:US
Mailing Address - Phone:317-626-7566
Mailing Address - Fax:
Practice Address - Street 1:8606 ALLISONVILLE RD
Practice Address - Street 2:SUITE 219
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-5515
Practice Address - Country:US
Practice Address - Phone:317-626-7566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0041801041C0700X
IN34005136A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical