Provider Demographics
NPI:1538283031
Name:MARTIN, NICOLE GREGORY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:GREGORY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E DRIFTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NAGS HEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27959-9173
Mailing Address - Country:US
Mailing Address - Phone:252-207-3701
Mailing Address - Fax:252-441-3057
Practice Address - Street 1:113 E SOTHEL ST
Practice Address - Street 2:SUITE 6
Practice Address - City:KILL DEVIL HILLS
Practice Address - State:NC
Practice Address - Zip Code:27948-6961
Practice Address - Country:US
Practice Address - Phone:252-207-3701
Practice Address - Fax:252-441-3057
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4519101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102427Medicaid