Provider Demographics
NPI:1649480625
Name:MARTIN, PAULA SHANE (MS,LSW,LMHC)
Entity type:Individual
Prefix:MS
First Name:PAULA
Middle Name:SHANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS,LSW,LMHC
Other - Prefix:MS
Other - First Name:PAULA
Other - Middle Name:SCARUTHERS
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3404
Mailing Address - Country:US
Mailing Address - Phone:260-481-2700
Mailing Address - Fax:
Practice Address - Street 1:909 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-3513
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001302A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health