Healthcare Provider Details

I. General information

NPI: 1215847132
Provider Name (Legal Business Name): MARTINA MARTIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

130 BENNINGTON POINTE
MADISON MS
39110-8741
US

IV. Provider business mailing address

130 BENNINGTON POINTE
MADISON MS
39110-8741
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-2814
  • Fax:
Mailing address:
  • Phone: 601-665-2814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-10917
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: