Healthcare Provider Details

I. General information

NPI: 1043651854
Provider Name (Legal Business Name): MARTHA L BOYER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTHA PACK

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 N SAINT ASAPH ST
ALEXANDRIA VA
22314-1912
US

IV. Provider business mailing address

320 BALLENTINE ESTATES RD
IRMO SC
29063-8905
US

V. Phone/Fax

Practice location:
  • Phone: 703-746-3400
  • Fax: 703-746-3464
Mailing address:
  • Phone: 803-444-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008067
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12407
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: