Provider Demographics
NPI:1104174648
Name:MARTIN, LOLA GABRIELLE (LCSW)
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:GABRIELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LOLA
Other - Middle Name:GABRIELLE
Other - Last Name:SCHELLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:13033 229TH ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1838
Mailing Address - Country:US
Mailing Address - Phone:917-531-1295
Mailing Address - Fax:
Practice Address - Street 1:13033 229TH ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1838
Practice Address - Country:US
Practice Address - Phone:917-531-1295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081659104100000X
NY0884001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker