Provider Demographics
NPI:1356055719
Name:MARTIN, EVAN (LMSW)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 BOULEVARD SE APT H217
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-2386
Mailing Address - Country:US
Mailing Address - Phone:301-653-9878
Mailing Address - Fax:
Practice Address - Street 1:3301 BELAIR RD STE 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1257
Practice Address - Country:US
Practice Address - Phone:443-873-7193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25828104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker