1396863791 NPI number — LORI A MARTIN LCSW

Table of content: LORI A MARTIN LCSW (NPI 1396863791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396863791 NPI number — LORI A MARTIN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
LORI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396863791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADAWASKA
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04756-0602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-436-9587
Provider Business Mailing Address Fax Number:
207-728-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
272 MAIN STREET SUITE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADAWASKA
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04756-0602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-436-9587
Provider Business Practice Location Address Fax Number:
207-728-3131
Provider Enumeration Date:
03/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LC11621 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 431878499 . This is a "MAINE CARE NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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