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General NPI Number Information
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NPI Number | 1629068622
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Entity Type | Individual
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Provider Name | MARK ALLEN MARTELLO LCSW
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Gender | Male
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Dates
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Enumeration Date | 10/21/2005
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Last Update Date | 09/10/2019
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Provider Practice Location Address
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Address Line | 325 E H ST
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City | IRON MOUNTAIN
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State | MI
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Zip | 49801-4760
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Country | US
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Telephone | 906-774-3300
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Fax |
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Provider Business Mailing Address
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Address Line | N10994 SPRING CREEK DR
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City | TOMAHAWK
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State | WI
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Zip | 54487-9718
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Country | US
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Telephone | 808-754-5504
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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 | 8830-123
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-1205
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License Number State | ID
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