Provider Demographics
NPI:1083912117
Name:MARTIN, EBONIQUE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:EBONIQUE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 HARMON DR APT B6
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-8477
Mailing Address - Country:US
Mailing Address - Phone:229-232-9061
Mailing Address - Fax:877-343-0538
Practice Address - Street 1:2109 N PATTERSON ST STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2577
Practice Address - Country:US
Practice Address - Phone:229-232-4833
Practice Address - Fax:877-343-0538
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001168106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA001168Other001168