Healthcare Provider Details

I. General information

NPI: 1396863791
Provider Name (Legal Business Name): LORI A MARTIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 MAIN STREET SUITE 103
MADAWASKA ME
04756-0602
US

IV. Provider business mailing address

PO BOX 602
MADAWASKA ME
04756-0602
US

V. Phone/Fax

Practice location:
  • Phone: 207-436-9587
  • Fax: 207-728-3131
Mailing address:
  • Phone: 207-436-9587
  • Fax: 207-728-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC11621
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: