Healthcare Provider Details

I. General information

NPI: 1528952926
Provider Name (Legal Business Name): MICHAEL GERHARD MARTIN LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 SAXTONS RIVER RD
SAXTONS RIVER VT
05154-9701
US

IV. Provider business mailing address

940 SAXTONS RIVER RD
SAXTONS RIVER VT
05154-9701
US

V. Phone/Fax

Practice location:
  • Phone: 802-376-1516
  • Fax:
Mailing address:
  • Phone: 508-423-2369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0136582
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: