Provider Demographics
NPI:1558882043
Name:AZURE PSYCHOTHERAPY, PLLC
Entity Type:Organization
Organization Name:AZURE PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCMHC
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:239-961-0284
Mailing Address - Street 1:5200 PARK RD STE 108
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3675
Mailing Address - Country:US
Mailing Address - Phone:239-961-0284
Mailing Address - Fax:
Practice Address - Street 1:5200 PARK ROAD
Practice Address - Street 2:STE 108
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3675
Practice Address - Country:US
Practice Address - Phone:239-961-0284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1144524158Medicaid