Healthcare Provider Details

I. General information

NPI: 1285559880
Provider Name (Legal Business Name): MARY MONIQUE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SOUTH BLVD STE 202
VIRGINIA BEACH VA
23452-1160
US

IV. Provider business mailing address

3419 VIRGINIA BEACH BLVD # 800
VIRGINIA BEACH VA
23452-4419
US

V. Phone/Fax

Practice location:
  • Phone: 757-340-6100
  • Fax:
Mailing address:
  • Phone: 757-340-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020829
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: