1316663149 NPI number — DAJA JEAN MARTIN LMSW-CC

Table of content: DAJA JEAN MARTIN LMSW-CC (NPI 1316663149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316663149 NPI number — DAJA JEAN MARTIN LMSW-CC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
DAJA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW-CC
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:
1316663149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
C/O ST MARYS HEALTH SYSTEM- PROVIDER ENROLLMENT
Provider Second Line Business Mailing Address:
PO BOX 7291, LEWISTON, ME 04243-7291
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-777-8950
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1230 MAINE ST RM A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04274-7325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-998-4483
Provider Business Practice Location Address Fax Number:
207-998-2189
Provider Enumeration Date:
10/13/2022

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: 104100000X , with the licence number:  MC21571 , 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)





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