MEDICARE: MS. TIA ELISE 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	0904003717	VA

General Provider Information

NPI Number	:	1255681276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TIA ELISE MARTIN LCSW

Provider Business Mailing Address
First Line	:	911 WHISPERING PINES TRL SW
Second Line	:
City	:	DECATUR
State	:	AL
Zip	:	35603-3201
Country	:	US
Telephone Number	:	256-552-7540
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 WHISPERING PINES TRL SW
Second Line	:
City	:	DECATUR
State	:	AL
Zip	:	35603-3201
Country	:	US
Telephone Number	:	256-552-7540
Fax Number	:

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

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	09/17/2012

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