Healthcare Provider Details

I. General information

NPI: 1255732111
Provider Name (Legal Business Name): ELAINE MARTIN, LICSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 WAYLAND AVE SUITE 1
PROVIDENCE RI
02906-4318
US

IV. Provider business mailing address

39 TOWNSEND ST
BARRINGTON RI
02806-1417
US

V. Phone/Fax

Practice location:
  • Phone: 401-354-9372
  • Fax: 401-709-3776
Mailing address:
  • Phone: 401-354-9372
  • Fax: 401-709-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000638ISW
License Number StateRI

VIII. Authorized Official

Name: ELAINE LOUISE MARTIN
Title or Position: SOLE MEMBER
Credential: LICSW
Phone: 401-354-9372