Provider Demographics
NPI:1558836080
Name:MARTIN, OLIVIA LONG (LPC)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LONG
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 1:231 GRAYHAWK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4010
Mailing Address - Country:US
Mailing Address - Phone:601-751-4180
Mailing Address - Fax:601-429-1186
Practice Address - Street 1:231 GRAYHAWK DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-4010
Practice Address - Country:US
Practice Address - Phone:601-751-4180
Practice Address - Fax:601-429-1186
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2206101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional