Provider Demographics
NPI:1346003522
Name:MARTIN, CARLY (MS, LPCA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MS, LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 14TH CT
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-5112
Mailing Address - Country:US
Mailing Address - Phone:860-799-4008
Mailing Address - Fax:
Practice Address - Street 1:52 FOREST AVE
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5732
Practice Address - Country:US
Practice Address - Phone:203-313-1043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6014101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health