MEDICARE: MARY EDNA WANDA MARTIN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1869C	AL
2	1041C0700X	Clinical Social Worker	CSW005133	GA

General Provider Information

NPI Number	:	1235002924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY EDNA WANDA MARTIN LCSW

Provider Business Mailing Address
First Line	:	819 LEE ROAD 219
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36870-8723
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	819 LEE ROAD 219
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36870-8723
Country	:	US
Telephone Number	:	706-761-6885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2025
Last Update Date	:	09/29/2025

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