Provider Demographics
NPI:1447042767
Name:MARTIN, MICHELLE SUSANNE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUSANNE
Last Name:MARTIN
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 1:3733 N KINGS PEAK CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-7745
Mailing Address - Country:US
Mailing Address - Phone:480-528-3084
Mailing Address - Fax:
Practice Address - Street 1:3733 N KINGS PEAK CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-7745
Practice Address - Country:US
Practice Address - Phone:480-528-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-229961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical