Healthcare Provider Details

I. General information

NPI: 1659039121
Provider Name (Legal Business Name): CARROLL MARTIN LCSW - LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41631 OLIVINE PL
ALDIE VA
20105-5682
US

IV. Provider business mailing address

41631 OLIVINE PL
ALDIE VA
20105-5682
US

V. Phone/Fax

Practice location:
  • Phone: 703-775-4102
  • Fax:
Mailing address:
  • Phone: 703-775-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CARROLL MARTIN
Title or Position: OWNER / CEO
Credential: LCSW
Phone: 540-406-1717