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NPI Code Detail

MEDICARE: CORNELIUS MARTIN LCSW

MEDICARE: CORNELIUS 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
11041C0700XClinical Social WorkerS18803TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
186478QOTHERBC/BS
29398151OTHERPHCS

General Provider Information

NPI Number : 1316977184
Entity Type Code : Individual
Provider Name (Legal Business Name) : CORNELIUS MARTIN LCSW
Provider Business Mailing Address
First Line : 4054 MCKINNEY AVE STE 102
Second Line :
City : DALLAS
State : TX
Zip : 75204-2050
Country : US
Telephone Number : 214-520-6308
Fax Number :
Provider Business Practice Location Address
First Line : 4054 MCKINNEY AVE STE 102
Second Line :
City : DALLAS
State : TX
Zip : 75204-2050
Country : US
Telephone Number : 214-520-6308
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/04/2006
Last Update Date : 07/08/2007

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Directions to “ CORNELIUS MARTIN LCSW” Practice Location

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