Healthcare Provider Details

I. General information

NPI: 1811054950
Provider Name (Legal Business Name): DENNIS MICHAEL MARTIN LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 HIGH ST
FALL RIVER MA
02720-3306
US

IV. Provider business mailing address

147 VALENTINE ST
FALL RIVER MA
02720-4223
US

V. Phone/Fax

Practice location:
  • Phone: 509-677-9091
  • Fax:
Mailing address:
  • Phone: 508-677-0983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106342
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierP08357
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBLUE CROSS OF MASSACHUSET

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: