MEDICARE: ANGELA MARTIN PSYCHOTHERAPY, LLC

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	6568-123	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578688057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELA MARTIN PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	5930 5TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53140-4214
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6021 DURAND AVE
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53406-5096
Country	:	US
Telephone Number	:	262-554-0126
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. ANGELA MARTIN
Credential	:	LCSW
Telephone Number	:	262-515-3220

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	08/22/2020

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