Healthcare Provider Details

I. General information

NPI: 1639187461
Provider Name (Legal Business Name): ELAINE LOUISE MARTIN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RICHMOND SQ STE 232E
PROVIDENCE RI
02906-5139
US

IV. Provider business mailing address

1 RICHMOND SQ STE 232E
PROVIDENCE RI
02906-5139
US

V. Phone/Fax

Practice location:
  • Phone: 401-354-9372
  • Fax: 401-633-6739
Mailing address:
  • Phone: 401-354-9372
  • Fax: 401-633-6739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW00638
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: