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General NPI Number Information
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NPI Number | 1215327374
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Entity Type | Individual
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Provider Name | WAYNE MARTIN LCSW
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Gender | Male
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Dates
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Enumeration Date | 01/28/2015
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Last Update Date | 11/08/2019
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Provider Practice Location Address
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Address Line | 2501 PARKVIEW DR SUITE 304
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City | FORT WORTH
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State | TX
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Zip | 76102-5824
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Country | US
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Telephone | 817-456-3489
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Fax |
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Provider Business Mailing Address
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Address Line | 1751 RIVER RUN STE 200
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City | FORT WORTH
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State | TX
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Zip | 76107-6670
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Country | US
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Telephone | 817-456-3489
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | S19454
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License Number State | TX
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