Basic Information
| Provider Information | |||||||||
| NPI: | 1356312789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | A. (INITIAL ONLY) | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1827 LONGDALE DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235184943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579535269 | ||||||||
| FaxNumber: | 7579536907 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | OUTPATIENT PSYCHIATRY CLINIC, NMCP | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579535269 | ||||||||
| FaxNumber: | 7579536907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904000158 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.