Provider Demographics
NPI:1770986416
Name:MARTIN, DEMETRIA (LCSW,CTRS,CLC)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW,CTRS,CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 STRADA CIR STE 220
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3209
Mailing Address - Country:US
Mailing Address - Phone:469-224-7679
Mailing Address - Fax:
Practice Address - Street 1:600 STRADA CIR STE 220
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3209
Practice Address - Country:US
Practice Address - Phone:469-224-7679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-08
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA102181041C0700X
222Q00000X
48665225800000X
TX543321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist