Provider Demographics
NPI:1558937920
Name:DE LA TORRE, MARTHA L (LAC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:L
Last Name:DE LA TORRE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-3406
Mailing Address - Country:US
Mailing Address - Phone:308-207-5148
Mailing Address - Fax:
Practice Address - Street 1:4925 S BROADWAY AVE # 1044
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67216-3716
Practice Address - Country:US
Practice Address - Phone:308-207-5148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19574101YM0800X
KS3315101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health