Provider Demographics
NPI:1902883283
Name:CARTER, MARTHA SUSAN (LICSW)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:SUSAN
Last Name:CARTER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVENUE WEST
Mailing Address - Street 2:SUITE 229N
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114
Mailing Address - Country:US
Mailing Address - Phone:651-645-3115
Mailing Address - Fax:654-645-2752
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:612-863-8511
Practice Address - Fax:612-863-8516
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15337104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN176648100Medicaid
200RICAOtherBCBS OF MN