Provider Demographics
NPI:1427143783
Name:PHELPS, MARTHA M (LCSW)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:M
Last Name:PHELPS
Suffix:
Gender:F
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:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34451-0711
Mailing Address - Country:US
Mailing Address - Phone:352-637-0605
Mailing Address - Fax:352-637-0706
Practice Address - Street 1:1127 STERLING RD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34450-3979
Practice Address - Country:US
Practice Address - Phone:352-637-0605
Practice Address - Fax:352-637-0706
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW72281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7610386 00Medicaid