Basic Information
| Provider Information | |||||||||
| NPI: | 1972523561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EARLY | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LCAS, CCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 936 | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235010936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 FAIRFAX AVE | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235071914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574465955 | ||||||||
| FaxNumber: | 7574465196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 732 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C002940 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 0904003705 | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1972523561 | 01 | VA | VALUE OPTIONS | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | PAR | 01 | VA | VIRGINIA PREMIER HEALTH | OTHER | PAR | 01 | VA | AETNA | OTHER | PAR | 01 | VA | USA MANAGED CARE | OTHER | PAR | 01 | VA | CORVEL/CORECARE | OTHER | 1972523561 | 01 | VA | COVENTRY HEALTH | OTHER | 2711554 | 01 | VA | CIGNA BEHAVIORAL HEALTH | OTHER | 365405 | 01 | VA | ANTHEM BEHAVIORAL HEALTH (PORTSMOUTH FAMILY MEDICINE) | OTHER | 600538-662 | 01 | VA | MAGELLAN HEALTH SERVICES | OTHER | PAR | 01 | VA | VIRGINIA HEALTH NETWORK | OTHER | PAR | 01 | VA | SENTARA/OPTIMA BEHAVIORAL HEALTH | OTHER | 365403 | 01 | VA | ANTHEM BEHAVIORAL HEALTH (GHENT FAMILY MEDICINE) | OTHER | 1972523561 | 05 | VA | MEDICAID |