Provider Demographics
NPI:1912392010
Name:MARTIN, RETA PASSWATERS (LCSW)
Entity Type:Individual
Prefix:
First Name:RETA
Middle Name:PASSWATERS
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9109 OAK PRIDE CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3362
Mailing Address - Country:US
Mailing Address - Phone:443-562-2347
Mailing Address - Fax:
Practice Address - Street 1:421 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6138
Practice Address - Country:US
Practice Address - Phone:813-315-8648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 124891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical