Provider Demographics
NPI:1255588455
Name:JUDITH A MARTIN L.C.S.W., P.C.
Entity type:Organization
Organization Name:JUDITH A MARTIN L.C.S.W., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-957-9106
Mailing Address - Street 1:2385 NW CABRILLO CT
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6041
Mailing Address - Country:US
Mailing Address - Phone:541-957-9106
Mailing Address - Fax:
Practice Address - Street 1:2385 NW CABRILLO CT
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6041
Practice Address - Country:US
Practice Address - Phone:541-957-9106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR21648Medicare UPIN
OR100716Medicare PIN