MEDICARE: MS. CAROL ANNE MARTIN MSW-ASW

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	14765	CA

General Provider Information

NPI Number	:	1841301348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL ANNE MARTIN MSW-ASW

Provider Business Mailing Address
First Line	:	1049 12TH ST
Second Line	:
City	:	IMPERIAL BEACH
State	:	CA
Zip	:	91932-2930
Country	:	US
Telephone Number	:	619-423-7656
Fax Number	:

Provider Business Practice Location Address
First Line	:	6160 MISSION GORGE RD
Second Line	:	120
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-3410
Country	:	US
Telephone Number	:	619-283-5731
Fax Number	:	619-283-1877

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/21/2008

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