Healthcare Provider Details

I. General information

NPI: 1629421904
Provider Name (Legal Business Name): ABIGAIL MARTIN LICSW
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: CHARLIE MARTIN LICSW

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 NEWTON ST
BROCKTON MA
02301-5115
US

IV. Provider business mailing address

329 POND ST APT 1
BRAINTREE MA
02184-6857
US

V. Phone/Fax

Practice location:
  • Phone: 508-583-6498
  • Fax:
Mailing address:
  • Phone: 617-903-2840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1140184
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: