Healthcare Provider Details

I. General information

NPI: 1700164696
Provider Name (Legal Business Name): MICHAEL MARTIN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 E 188TH ST 5TH FLOOR
BRONX NY
10458-5302
US

IV. Provider business mailing address

260 E 188TH ST 5TH FLOOR
BRONX NY
10458-5302
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-3382
  • Fax: 718-933-2502
Mailing address:
  • Phone: 718-960-3382
  • Fax: 718-933-2502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number083282
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: