Provider Demographics
NPI:1598882847
Name:MARTIN, LISA (LPC, LMFT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 BLUEBONNET DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-3023
Mailing Address - Country:US
Mailing Address - Phone:830-459-0013
Mailing Address - Fax:830-896-3343
Practice Address - Street 1:913 BLUEBONNET DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-3023
Practice Address - Country:US
Practice Address - Phone:830-459-0013
Practice Address - Fax:830-896-3343
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14363101YP2500X
TX004856-042659106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0958043-01Medicaid
TX5305LCOtherBCBS PROVIDER NUMBER