MEDICARE: MS. ETTA LOUISE 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	LCS21526	CA

General Provider Information

NPI Number	:	1487639852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ETTA LOUISE MARTIN LCSW

Provider Business Mailing Address
First Line	:	4201 VENTURA CANYON AVE
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91423-4329
Country	:	US
Telephone Number	:	818-789-8784
Fax Number	:	818-905-2845

Provider Business Practice Location Address
First Line	:	4911 VAN NUYS BLVD
Second Line	:	SUITE 102
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-1716
Country	:	US
Telephone Number	:	818-817-3248
Fax Number	:	818-905-2845

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

Provider Enumeration Date	:	12/08/2005
Last Update Date	:	07/08/2007

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