Provider Demographics
NPI:1316635188
Name:MARTIN, MALISSA DENAE (LMSW)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:DENAE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MALISSA
Other - Middle Name:D
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39 FLANDERS STREET
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096
Mailing Address - Country:US
Mailing Address - Phone:478-247-9553
Mailing Address - Fax:
Practice Address - Street 1:39 FLANDERS STREET
Practice Address - Street 2:
Practice Address - City:WRIGHTSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31096
Practice Address - Country:US
Practice Address - Phone:478-247-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW010826104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker