Provider Demographics
NPI:1518361500
Name:LEBEN-MARTIN, PETRICE (LMHC)
Entity Type:Individual
Prefix:
First Name:PETRICE
Middle Name:
Last Name:LEBEN-MARTIN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MCCLEAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4609
Mailing Address - Country:US
Mailing Address - Phone:718-791-1030
Mailing Address - Fax:
Practice Address - Street 1:657 CASTLETON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2028
Practice Address - Country:US
Practice Address - Phone:718-818-6583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health