Healthcare Provider Details

I. General information

NPI: 1083773337
Provider Name (Legal Business Name): ANN L MARTIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SW 8TH ST
REDMOND OR
97756-2114
US

IV. Provider business mailing address

124 SW 8TH ST
REDMOND OR
97756-2114
US

V. Phone/Fax

Practice location:
  • Phone: 541-504-8970
  • Fax: 541-504-5805
Mailing address:
  • Phone: 541-504-8970
  • Fax: 541-504-5805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3365
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: