Healthcare Provider Details

I. General information

NPI: 1063429595
Provider Name (Legal Business Name): DIANNE MARTAUS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 EAST MAIN STREET
MARSHALL AR
72650
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 870-448-2176
  • Fax:
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-4843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1433C
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: