Basic Information
| Provider Information | |||||||||
| NPI: | 1538802640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TYRA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430853192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148443800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22 N 1ST ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430555608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148443800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2022 | ||||||||
| LastUpdateDate: | 04/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.2004794 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 2615030 | 05 | OH | MEDICAID |