Provider Demographics
NPI:1811184393
Name:MARTIN, KATHLEEN NOLAN (LCSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NOLAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MEGGAN
Other - Last Name:NOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4310 METRO PKWY
Mailing Address - Street 2:STE 205
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9416
Mailing Address - Country:US
Mailing Address - Phone:239-236-8784
Mailing Address - Fax:239-790-2624
Practice Address - Street 1:2305 N PARHAM RD STE 3
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-3156
Practice Address - Country:US
Practice Address - Phone:804-399-3515
Practice Address - Fax:804-270-2090
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW120381041C0700X
VA09040066601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945255Medicaid
VAC04867Medicare PIN