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NPI Code Detail

MEDICARE: MR. MARK ALLEN MARTELLO LCSW

MEDICARE: MR. MARK ALLEN MARTELLO 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 Worker8830-123WI
21041C0700XClinical Social WorkerLCSW-1205ID

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1LCSW-1205OTHERIDSTATE LICENSE

General Provider Information

NPI Number : 1629068622
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARK ALLEN MARTELLO LCSW
Provider Business Mailing Address
First Line : N10994 SPRING CREEK DR
Second Line :
City : TOMAHAWK
State : WI
Zip : 54487-9718
Country : US
Telephone Number : 808-754-5504
Fax Number :
Provider Business Practice Location Address
First Line : 325 E H ST
Second Line :
City : IRON MOUNTAIN
State : MI
Zip : 49801-4760
Country : US
Telephone Number : 906-774-3300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/21/2005
Last Update Date : 09/10/2019

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