Healthcare Provider Details

I. General information

NPI: 1336957836
Provider Name (Legal Business Name): SHANA J MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2024
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 EASTPORT CENTRE DR
VALPARAISO IN
46383-4457
US

IV. Provider business mailing address

528 N STATE ROAD 149
VALPARAISO IN
46385-8833
US

V. Phone/Fax

Practice location:
  • Phone: 219-386-3386
  • Fax: 219-245-6115
Mailing address:
  • Phone: 219-916-3154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33012767A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: