Provider Demographics
NPI:1720429749
Name:MARTIN, ERIN KIM (LISW-S, LICDC)
Entity Type:Individual
Prefix:MS
First Name:ERIN
Middle Name:KIM
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 851 BOX 1644
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09834-0017
Mailing Address - Country:US
Mailing Address - Phone:318-439-9357
Mailing Address - Fax:
Practice Address - Street 1:BLDG 4066, 602ND ST
Practice Address - Street 2:
Practice Address - City:FT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703
Practice Address - Country:US
Practice Address - Phone:907-361-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1200780104100000X
OHI.14508301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker