Provider Demographics
NPI:1497904312
Name:LAKE MARTIN FAMILY THERAPY, LLC
Entity Type:Organization
Organization Name:LAKE MARTIN FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LCSW
Authorized Official - Phone:256-625-9514
Mailing Address - Street 1:PO BOX 911
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35011-0911
Mailing Address - Country:US
Mailing Address - Phone:256-625-9514
Mailing Address - Fax:256-825-6418
Practice Address - Street 1:393 GREEN ST
Practice Address - Street 2:
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-1407
Practice Address - Country:US
Practice Address - Phone:256-625-9514
Practice Address - Fax:256-825-6418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2121C1041C0700X
ALL 299106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALL 299OtherALABAMA BOARD OF EXAMINERS IN MARRIAGE & FAMILY THERAPY
AL2121COtherSTATE OF ALABAMA BOARD OF SOCIAL WORK EXMAINERS
AL1652Medicare PIN