Basic Information
| Provider Information | |||||||||
| NPI: | 1619221710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | CHERI | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3033 N CENTRAL AVE STE 145 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235833001 | ||||||||
| FaxNumber: | 6239746721 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852016920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
| FaxNumber: | 4807189477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2012 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 252917 | KY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCSW-17502 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.