Provider Demographics
NPI:1336957836
Name:MARTIN, SHANA J
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 N STATE ROAD 149
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8833
Mailing Address - Country:US
Mailing Address - Phone:219-916-3154
Mailing Address - Fax:
Practice Address - Street 1:954 EASTPORT CENTRE DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4457
Practice Address - Country:US
Practice Address - Phone:219-386-3386
Practice Address - Fax:219-245-6115
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33012767A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker