MEDICARE: MRS. MARY E 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	CW014765	PA

General Provider Information

NPI Number	:	1275654642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY E MARTIN LCSW

Provider Business Mailing Address
First Line	:	41 MARY LN
Second Line	:
City	:	WAPWALLOPEN
State	:	PA
Zip	:	18660-8851
Country	:	US
Telephone Number	:	570-417-2830
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 MARY LN
Second Line	:
City	:	WAPWALLOPEN
State	:	PA
Zip	:	18660-8851
Country	:	US
Telephone Number	:	570-417-2830
Fax Number	:

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

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	04/13/2011

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