Provider Demographics
NPI:1609220896
Name:MARTIN, MARY (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 BUTLER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:COCOLALLA
Mailing Address - State:ID
Mailing Address - Zip Code:83813-9633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:231 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1423
Practice Address - Country:US
Practice Address - Phone:208-920-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5894101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health