Provider Demographics
NPI:1518082403
Name:LOFTIS, MARTHA SAMPLE (NCC, LPC)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:SAMPLE
Last Name:LOFTIS
Suffix:
Gender:F
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3813 IRON WORKS RD
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-8420
Mailing Address - Country:US
Mailing Address - Phone:704-500-2249
Mailing Address - Fax:
Practice Address - Street 1:3813 IRON WORKS RD
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-8420
Practice Address - Country:US
Practice Address - Phone:704-500-2249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4714101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103223Medicaid