Healthcare Provider Details

I. General information

NPI: 1801509468
Provider Name (Legal Business Name): MADELYN ANTLE MARTIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELYN JAYNE ANTLE LMSW

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13582 BLACKWATER RD
BAKER LA
70714-6800
US

IV. Provider business mailing address

1058 E WORTHY ST STE B-2
GONZALES LA
70737-4359
US

V. Phone/Fax

Practice location:
  • Phone: 225-930-8058
  • Fax:
Mailing address:
  • Phone: 225-450-3216
  • Fax: 225-450-3799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number17705
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: