Provider Demographics
NPI:1598162612
Name:MARTIN, TENNIS SHANE (LPC, MA)
Entity Type:Individual
Prefix:
First Name:TENNIS
Middle Name:SHANE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11059 E. BETHANY DRIVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014
Mailing Address - Country:US
Mailing Address - Phone:303-617-2300
Mailing Address - Fax:303-617-2365
Practice Address - Street 1:1390/1400 CHAMBERS RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011
Practice Address - Country:US
Practice Address - Phone:719-429-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO356101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12781010OtherCAQH