Healthcare Provider Details

I. General information

NPI: 1417002197
Provider Name (Legal Business Name): LISA R MARTIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 PATRICK DR
PATRICK AFB FL
32925-3606
US

IV. Provider business mailing address

455 INDIAN CREEK DR
COCOA BEACH FL
32931-2833
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-8234
  • Fax: 321-494-8074
Mailing address:
  • Phone: 321-784-3532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW2979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: