Provider Demographics
NPI:1235583097
Name:MARTIN, LAURA (MA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 SUGAR MILL LOOP
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-4631
Mailing Address - Country:US
Mailing Address - Phone:843-446-9217
Mailing Address - Fax:
Practice Address - Street 1:110 YE OLDE KINGS HWY
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-4384
Practice Address - Country:US
Practice Address - Phone:843-663-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5961101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health