Provider Demographics
NPI:1326342098
Name:MARTIN, EVA DIANE (MS, LPC)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:DIANE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 MARIETTA HIGHWAY
Mailing Address - Street 2:SUITE 146
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:470-253-7252
Mailing Address - Fax:800-397-1710
Practice Address - Street 1:2920 MARIETTA HIGHWAY
Practice Address - Street 2:SUITE 146
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:470-253-7252
Practice Address - Fax:800-397-1710
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC001690101YP2500X, 101YS0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003106189BMedicaid