Provider Demographics
NPI:1124111299
Name:MARTIN, JOHN (LCSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 OLD COLONY FARM RD SW
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-9595
Mailing Address - Country:US
Mailing Address - Phone:866-325-5434
Mailing Address - Fax:866-324-5340
Practice Address - Street 1:1050 CROWN POINTE PKWY
Practice Address - Street 2:SUITE 295
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-7707
Practice Address - Country:US
Practice Address - Phone:866-325-5434
Practice Address - Fax:866-325-5340
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0005171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical