Provider Demographics
NPI:1780095414
Name:MODEL, MARTIN (MSW)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MODEL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 FLORIDA RD APT 23
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-4486
Mailing Address - Country:US
Mailing Address - Phone:970-563-4581
Mailing Address - Fax:970-563-0208
Practice Address - Street 1:1200 FLORIDA RD APT 23
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4486
Practice Address - Country:US
Practice Address - Phone:970-563-4581
Practice Address - Fax:970-563-0208
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9830151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07983018Medicaid