Provider Demographics
NPI:1255665857
Name:MARTIN, PETREA MARY (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:PETREA
Middle Name:MARY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14419 COUNTY ROAD 323
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MT
Mailing Address - Zip Code:59213-9510
Mailing Address - Country:US
Mailing Address - Phone:406-787-5500
Mailing Address - Fax:406-787-5500
Practice Address - Street 1:400 4TH AVENUE WEST
Practice Address - Street 2:
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255
Practice Address - Country:US
Practice Address - Phone:406-768-6763
Practice Address - Fax:406-768-6802
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1159-LCPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health