Provider Demographics
NPI:1134464282
Name:MARTIN, ALLYCE
Entity Type:Individual
Prefix:
First Name:ALLYCE
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 N WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4576
Mailing Address - Country:US
Mailing Address - Phone:479-464-1060
Mailing Address - Fax:479-271-6307
Practice Address - Street 1:1316 MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-4557
Practice Address - Country:US
Practice Address - Phone:479-471-6892
Practice Address - Fax:479-471-6859
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor