Provider Demographics
NPI:1568679116
Name:MARTIN, BONNIE (LPC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
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 1:201 N FAIRFAX ST STE 14
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2674
Mailing Address - Country:US
Mailing Address - Phone:240-476-7671
Mailing Address - Fax:877-447-0147
Practice Address - Street 1:201 N FAIRFAX ST # 14
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2674
Practice Address - Country:US
Practice Address - Phone:703-746-3485
Practice Address - Fax:703-746-3464
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005008101YP2500X, 101YM0800X
MDLC2796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447279658Medicaid