Healthcare Provider Details

I. General information

NPI: 1871222364
Provider Name (Legal Business Name): MARY CHARLOTTE MARTIN LMSW-CLINICAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 3RD AVE S
ESCANABA MI
49829-1258
US

IV. Provider business mailing address

2525 3RD AVE S
ESCANABA MI
49829-1258
US

V. Phone/Fax

Practice location:
  • Phone: 906-786-9300
  • Fax:
Mailing address:
  • Phone: 906-786-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801120262
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: